|Year : 2020 | Volume
| Issue : 4 | Page : 714-719
Challenges of residency training and early career doctors in Nigeria Phase II: Update on objectives, design, and rationale of study
Ugochukwu A Eze1, Musiliu Adetola Tolani2, Makinde Adebayo Adeniyi3, Vivian I Ogbonna4, Ogechukwu Isokariari4, C Igbokwe Martin5, Kehinde Kanmodi6, Khadija A Abdulraheem7, Ifeanyi Kelvin Egbuchulem8, Abdulmajid I Yahya9, Ibiyemi Oduyemi10, Vincent E Nwatah11, Elizabeth O Grillo12, Rereloluwa N Babalola5, Isibor Efosa13, Qudus O Lawal14, Taiwo A Alatishe15, Dabota Y Buowari16, Olumuyiwa E Ariyo17, Ugochukwu Mosanya18, Tope E Adeyemi19, Oluwaseyi Ogunsuji20, Oyinkansola Agaja21, Adedayo Williams22, Lawson Obazenu23, Aliyu Sokomba24, Olusegun Olaopa25, Kabir Durowade26, Olayinka Stephen Ilesanmi27, Oladimeji Adebayo28, on behalf of Research Collaboration Network RCN29
1 Clinical Services, Katsina Eye Centre, Katsina, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital Shika, Zaria, Nigeria
3 Department of Community Medicine, Federal Teaching Hospital, Ido-Ekiti, Nigeria
4 Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
5 Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
6 Dental Clinic, Kebbi Medical Centre, Kalgo, Nigeria
7 Department of Medical Microbiology, National Hospital, Abuja, Nigeria
8 Department of Surgery, University College Hospital, Ibadan, Nigeria
9 Department of Ear, Nose, and Throat, Head and Neck Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
10 Department of Child Oral Health, University College Hospital, Ibadan, Nigeria
11 Department of Paediatrics, National Hospital, Abuja, Nigeria
12 Department of Obstetrics & Gynaecology, Federal Medical Centre, Abeokuta, Nigeria
13 Department of Paediatrics, Irua Specialist Teaching Hospital, Irua, Nigeria
14 Department of Obstetrics and Gynaecology, Irua Specialist Teaching Hospital, Irua, Nigeria
15 Department of Psychiatry, Ladoke Akintola University of Technology Teaching Hospital, Ogbomosho, Nigeria
16 Accident and Emergency Department, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
17 Department of Internal Medicine, Medicine Federal Teaching Hospital, Ido-Ekiti, Nigeria
18 Department of Orthopaedic Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
19 Department of Child Dental Health, Faculty of Dentistry, Bayero University, Kano/ Aminu Kano Teaching Hospital, Kano, Nigeria
20 Department of Periodontology and Community Dentistry, University College Hospital, Ibadan, Nigeria
21 Department of Paediatrics, University College Hospital, Ibadan, Nigeria
22 Department of Family Medicine, University College Hospital, Ibadan, Nigeria
23 Department of Surgery, Federal Medical Centre, Nguru, Nigeria
24 Department of Community Medicine, Ahmadu Bello University Teaching Hospital Shika, Zaria, Nigeria
25 Department of Oral Maxillofacial Surgery, Afe Babalola University, Ado Ekiti, Nigeria
26 Department of Community Medicine, Federal Teaching Hospital, Ido-Ekiti; Department of Community Medicine, Afe Babalola University, Ado Ekiti, Nigeria
27 Department of Community Medicine, University of Ibadan, Ibadan, Nigeria
28 Department of Medicine, University College Hospital, Ibadan, Nigeria
|Date of Submission||23-Jul-2020|
|Date of Decision||12-Aug-2020|
|Date of Acceptance||01-Oct-2020|
|Date of Web Publication||24-Dec-2020|
Dr. Oladimeji Adebayo
Department of Medicine, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Early career doctors (ECDs) are a dynamic and highly mobile group of medical and dental practitioners who form a significant proportion of the health workforce in Nigeria. The challenges of residency training and ECDs in Nigeria CHARTING Phase I study explored limited challenges affecting ECDs under the broad themes of demography, workplace issues, and psychosocial issues. The CHARTING II was expanded to provide wider insight into the challenges of ECDs in Nigeria. Objective: This protocol aims to provide clear objectives including description of objectives, design, and rationale for the conduct of the proposed CHARTING II study which seeks to explore other components under the various themes of demographic, workplace, psychosocial issues affecting the ECDs in Nigeria, and which were not explored under CHARTING I. Methodology: This shall be a mixed study design that will combine qualitative and quantitative methods, to investigate 27 subthemes among 2000 ECDs spread across 31 centers, accredited by the Nigerian Association of Resident Doctors. Participants shall be selected using the multistage sampling method. The primary data will be generated using structured proforma and validated questionnaires, while administrative sources would serve as a source of secondary data. Data will be entered and analyzed using appropriate statistical software. Conclusion: CHARTING II study would provide more robust data and insight into the problems encountered by ECDs in Nigeria. This would in turn build a platform for institutional engagement and advocacy in order to drive relevant policies to mitigate these challenges.
Keywords: Early career doctors, Nigeria, residency, resident doctors, training
|How to cite this article:|
Eze UA, Tolani MA, Adeniyi MA, Ogbonna VI, Isokariari O, Martin C I, Kanmodi K, Abdulraheem KA, Egbuchulem IK, Yahya AI, Oduyemi I, Nwatah VE, Grillo EO, Babalola RN, Efosa I, Lawal QO, Alatishe TA, Buowari DY, Ariyo OE, Mosanya U, Adeyemi TE, Ogunsuji O, Agaja O, Williams A, Obazenu L, Sokomba A, Olaopa O, Durowade K, Ilesanmi OS, Adebayo O, on behalf of Research Collaboration Network RCN. Challenges of residency training and early career doctors in Nigeria Phase II: Update on objectives, design, and rationale of study. Niger J Med 2020;29:714-9
|How to cite this URL:|
Eze UA, Tolani MA, Adeniyi MA, Ogbonna VI, Isokariari O, Martin C I, Kanmodi K, Abdulraheem KA, Egbuchulem IK, Yahya AI, Oduyemi I, Nwatah VE, Grillo EO, Babalola RN, Efosa I, Lawal QO, Alatishe TA, Buowari DY, Ariyo OE, Mosanya U, Adeyemi TE, Ogunsuji O, Agaja O, Williams A, Obazenu L, Sokomba A, Olaopa O, Durowade K, Ilesanmi OS, Adebayo O, on behalf of Research Collaboration Network RCN. Challenges of residency training and early career doctors in Nigeria Phase II: Update on objectives, design, and rationale of study. Niger J Med [serial online] 2020 [cited 2021 Nov 29];29:714-9. Available from: http://www.njmonline.org/text.asp?2020/29/4/714/304753
| Introduction|| |
Early career doctors (ECDs) are doctors below the rank of consultants or principal medical officers (PMO). They constitute the membership of the National Association of Resident Doctors (NARD) and remain a significant backbone of the medical workforce in Nigeria. This group of doctors either provide medical services while getting trained (house officers and resident doctors) or provide services without simultaneous and regimented training (medical and dental officers below the rank of PMO/principal dental officers [PDO]).
The ECDs in Nigeria are constantly exposed to multifaceted challenges revolving around demographic, workplace, and psychosocial issues which make them contemplate emigration to countries in the search for better job satisfaction working conditions and remuneration, career progression, professional advancement, and improved quality of life. Tackling these challenges amounts to tackling one of the most significant problems bedeviling the health systems in Nigeria manpower.
Workplace issues refer to challenges confronting ECDs in the workplace and center around practice satisfaction, multidisciplinary team leadership issues, conflict and its resolution, training and skill acquisition, research, work schedules, and other work-related issues. Practice satisfaction or the lack of it has been reported to have a direct impact on the quality of care offered by practitioners and is an important driver of migration among ECDs.,,,
Globally, health institutions are multidisciplinary in nature and the role of the doctor is central in every health institution, where leadership skills are important attributes expected of a good doctor as the leader of the medical team. Challenges in leadership have been reported among ECDs in Nigeria and a case has been made for the incorporation of well-structured leadership modules in the training of Nigerian doctors at all levels. Furthermore, the multidimensional nature of interaction of medical doctors with other stakeholders in their workplace is a recipe for conflict, and the need to identify challenges in leadership and conflict management among them cannot be overemphasized for targets in leadership modules to be achieved., Residency training is considered an excellent form of clinical professional development. However, prospective trainees are still faced with training and skill development challenges, poor research knowledge and mentorship, inadequate funding, and institutional support.,,, Furthermore, the psychological ground, the high burden of burnout bedeviling ECDs in Nigeria as shown by a recent systematic review, calls for concern.,,,,
In Nigeria, there is no clear policy on the working hours of resident doctors, though the maximum limit of call duty for every doctor in Nigeria is 40 units per month. In reality, however, many ECDs work beyond this upper limit, to meet up with demands of the work amidst a limited workforce. The spillover result of all these problems is a negative effect on work and nonwork-related productivity of resident doctors. These issues could be a push factor for brain drain with its consequent strain on the already precarious balance of the demand and supply of ECDs in the country.
Although the CHARTING I study was largely successful, only 11 research themes were explored in about 800 participants across ten residency training centers. The goal of the CHARTING II study is to bridge the identified gaps in knowledge, geopolitical spread, and statistical power of the sample inherent in the first phase of the study. This will hopefully make for better generalization of the results across the country, so that the evidence-based data generated can be used to advocate system-wide reforms.
| Research Methodology|| |
The study will use a mixed methods study design (with quantitative and qualitative aspects) to investigate the challenges of ECDs in Nigeria and associated factors.
The study population includes ECDs who have completed basic training in Medicine and Dentistry/Dental Surgery who are undergoing housemanship, residency training, or below the rank of a PMO/PDO/consultant working in public health institutions.
This study will be carried out in 31 randomly selected public tertiary health institutions, spread across the six geopolitical zones in Nigeria. Nigeria has 36 states distributed across the six geopolitical zones. Within these zones are federal teaching hospitals, state teaching hospitals, federal medical centers, and specialist training institutions. A total of 14 NARD centers exist in the North-West, whereas North-Central and North-East have 13 and 11 centers, respectively. In southern Nigeria, 15 centers are domiciled in the South-West, 12 in the South-South, and 10 centers in the South-East geopolitical zone.
Sampling method (survey)
Multistage sampling will be done for the CHARTING phase II survey similar to previously described for Phase I. There would be recruitment of all willing and consenting participants from the selected departments in the centers for the study. The recruitment of the centers would be done to include the following geopolitical zones: North-West (5), North-Central (7), North-East (3), South-South (5), South-West (9), South-East (2) [Table 1] and [Figure 1]. The response rate of the entire centers would be noted.
|Table 1: Selected location of early career doctors in the geopolitical zones|
Click here to view
Selection of stakeholders/participants and site selection
Qualitative study participants shall be derived from members in the various participating centers. They would be continuously recruited, 6–12 per session for each theme until saturation is reached across all study sites for each theme. Efforts would be made that the participants are spread into at least 1–2 persons in each of the cadre (interns, registrars, senior registrars, medical officers, and senior medical officers) for each focus group discussion.
A total of 2000 ECDs across the country would be recruited in the survey. This was based on the expected frequency of 50%, to accommodate the nonavailability in some instances, of the prevalence rate of some of the issues to be explored. Confidence limit of 5% was used and the design effect was set at 4, based on the 31 clusters earmarked for the survey. The sample size calculation was done using StatCalc of Epi Info 7™ produced by the Centre for Disease Control and Prevention.
Inclusion and exclusion criteria
Inclusion and exclusion are as previously published.
Data collection tools
It will use structured questionnaires, focus group discussions, and secondary administrative data similar to Phase I.
Data collection procedure/protocol
Study data will be collected using the following collection procedures:
- Administrative data to determine the numerical strength, distribution, and profile of the members of the NARD in each local branch of the NARD's administrative structure will be collected
- Individual-level data from the 2000 eligible participants that will be recruited for the study through multistage sampling shall be collected through the structured proforma. Self-administered questionnaires would be used to collect sociodemographic data and the relevant subthemes to be explored in the survey [Table 2], [Figure 1]
- Data will be collected from other migration of ECDs, the supply rate, and the volume of ECDs
- Focused group discussions, in-depth interviews, and key informant interviews for qualitative data from selected members will be done to explore issues on the following themes “ECDs and workplace preparedness,” “deterrent of workplace standard precautions,” “workplace environment and academic performance,” “quality of training,” “substance abuse,” “mental health of ECDs,” themes, among others.
|Table 2: Proforma section, synopsis of variables that would be assessed, and tools to be used|
Click here to view
Focal group discussion/in-depth interview
Focal group discussion (FGD)/in-depth interview would be conducted in the various centres in the study. Each session of Focused Group Discussion (FGD) would have 6–12 participants in each session. The participants' recruitment into the qualitative arm of the study would be voluntary; only those participants who accepted after the invitation would be allowed to participate. Trained facilitators would collect data during the session of 45–90 min. There will be cessation if participants are tired. The facilitators would use a semi-structured FGD guide which would be carefully designed to encourage the participants to express themselves on the subtheme of discourse.
The discussions would be digitally recorded with the use of an audio recorder (Sony ICD-PX470 digital voice recorder), whereas a smartphone audio recorder was used as a backup/alternate plan, with participants consenting to ensure that the details of the conversations were adequately captured. The various groups would be engaged until data saturation is achieved (i. e., repetitive responses and lack of new information).
Collected data will be cleaned, coded, and entered into the IBM SPSS Statistics version 23 Chicago, IL, USA. The frequency distribution of all variables will be determined. Test of association between/among quantitative variables will be done using bivariate and multivariate analyses, with the level of statistical significance set at a P < 0.05.
Recorded interviews will be transcribed by two expert transcribers and the generated textual data will be analyzed using thematic approach. Themes and subthemes will be generated and supported with illustrative quotations from the interviews.
The approval for modification and extension for the previous study would be sought from the relevant National Ethics Review Committee of the Federal Ministry of Health and institutional approval from the participating institutions. Written informed consent shall be obtained from each prospective participant before participating in the study. The names of participants shall not be recorded to ensure anonymity. The database will be accessed by only approved research team members.
| Discussion|| |
The extension and modification of the CHARTING study seek to explore more challenges of residency training among ECDs. CHARTING Study I, which is the largest study among the ECDs in Nigeria, recruited about 800 participants from 10 centers. Key differences are the increased number of participants, more recruitment centers, and scope of subthemes to be explored. This would not only improve the power of the various outcomes but also exhaustively unravel and provide insight into many of the challenges bewildering ECDs in Nigeria.
The demographic issues to be explored have been expanded to include family life, as against emigration in the initial phase. The current phase would not just explore the profile of the burnout among ECDs but explore the validation of other tools among ECDs. It is anticipated that such validation would provide wider tools to explore these thematic issues among ECDs in the country. Furthermore, it will explore the interplay of these psychosocial factors and oral health, cardiovascular, and musculoskeletal risk. Issues related to the workplace environment, learning among ECDs, and quality of health service provision shall also be explored in this phase of the CHARTING Study.
The strength of the current phase is the larger power and spread of participants which would aid better generalization of the findings. The current phase will generate more evidence; this phase is expected to have 27 subsections in the survey proforma as against 11 sections in the pioneer study. It, therefore, promises to generate much more data and evidence on the challenges of ECDs in Nigeria which should be used for policy formulation among stakeholders in a bid to mitigate these challenges compare to the first phase., Furthermore, the findings shall contribute to the ever-growing body of knowledge of workplace issues among ECDs in our country, and appropriate implementation shall strengthen the nation's health system.
| Conclusion|| |
From the foregoing, it is evident that CHARTING PHASE II will give more insight into the numerous challenges that ECDs are fraught within Nigeria. Far-reaching recommendations shall be made in order to mitigate these challenges, improve the quality of life of ECDs, and by extension, the quality of health-care provision. Finally, if implemented, the health systems of Nigeria and Sub-Saharan Africa will be inevitably be strengthened.
The authors would like to thank the National Executive Council of NARD, the Research Collaboration Network (RCN), and advisors.
Financial support and sponsorship
This work is supported by the Nigerian Association of Resident Doctors (NARD)'s funding for Research & Statistics Committee (RSC)/Research Collaboration Network (RCN).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kanmodi K, Ekundayo O, Adebayo O, Efuntoye O, Ogunsuji O, Ibiyo M, et al
. Challenges of residency training and early career doctors in Nigeria study (charting study): A protocol paper. Niger J Med 2019;28:198-205. [Full text]
Adebayo O, Adufe I, Ayanfe O, Buowari DY, Onwuabuchi E, Efosa I, et al
. 'white coat drain; a monograph for migration of Nigerian doctors'. In: Adebayo O, Olaopa O, editors. White coat drain; a monograph for migration of Nigerian doctors. Abuja, Nigeria: National Association of Resident Doctors; 2019.
DeVoe J, Fryer Jr., GE, Hargraves JL, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? J Fam Pract 2002;51:223-8.
Pedrazza M, Berlanda S, Trifiletti E, Bressan F. Exploring Physicians' dissatisfaction and work-related stress: Development of the PhyDis Scale. Front Psychol 2016;7:1238.
Alon U. How to choose a good scientific problem. Mol Cell 2009;35:726-8.
Pathman DE, Konrad TR, Williams ES, Scheckler WE, Linzer M, Douglas J, et al
. Physician job satisfaction, dissatisfaction, and turnover. J Fam Pract 2002;51:593.
Isibor I, Kanmodi K, Adebayo O, Olaopa O, Igbokwe M, Adufe I, et al
. Exploring issues and challenges of leadership among early career doctors in Nigeria using a mixed-method approach: CHARTING Study. Eur J Investig Health Psychol Educ 2020;10:441-54.
Adebayo O, Akande T, Buowari DY, Ogunsuji O, Mahmudat YT. Managing conflicts at the workplace: Guide for early career doctors. In: Adebayo O, Olaopa O, editors. Managing conflicts at the workplace: Guide for early career doctors. Abuja, Nigeria: National Association of Resident Doctors; 2019.
Macedo PC, Cítero Vde A, Schenkman S, Nogueira-Martins MC, Morais MB, Nogueira-Martins LA. Health-related quality of life predictors during medical residency in a random, stratified sample of residents. Braz J Psychiatry 2009;31:119-24.
Ojo EO, Chirdan OO, Ajape AA, Agbo S, Oguntola AS, Adejumo AA, et al
. Post-graduate surgical training in Nigeria: The trainees' perspective, Niger Med J. 2014;55:342-47.
Eze BI, Nwadinigwe UC, Achor J, Aguwa EN, Mbah A, Ozoemena F. Trainee participation in research activities in resource constrained setting in south-eastern Nigeria: Perspectives, Issues and challenges. A cross sectional survey of three residency training centres. BMC Med Educ 2012;12:1-10.
Ibrahim YA, Olaopa O, Adebayo O, Efuntoye O, Oiwoh S, Salewo T, et al
. Attitude to research and challenges faced being researchers by early career doctors (ECDs) in Nigeria: A preliminary report from the CHARTING Study. Presentation at Nigerian Association of Resident Doctors of Nigeria AGM & Scientific Conference, Kaduna 2019.
Abdulraheem I, Adisa TA. Long Working Hours and the Challenges of Work Life Balance: The Case of Nigerian Medical Doctors. Conference Proceedings of British Academy of Management; 2016
Coker A, Adewole O, Shoga M, Uzodimma C. Burnout syndrome among orthopaedic surgeons in Lagos Nigeria. East Cent Afr J Surg 2012;17:13-7.
Lar-Ndam N, Madaki J, Pitmang L, Audu M, Salihu D, Gyang M. Burnout among primary care physicians in Jos-Plateau, Nort-central Nigeria. Niger J Fam Pract 2015;6:11-8.
Ogundipe OA, Olagunju AT, Lasebikan VO, Coker AO. Burnout among doctors in residency training in a tertiary hospital. Asian J Psychiatr 2014;10:27-32.
Ogunsuji OO, Adebayo O, Olaopa O, Efuntoye O, Agbogidi JM, Kanmodi K, et al
. Burnout among Nigerian Doctors: a systematic review. Niger Med Pract 2019;76:1-3.
Ogunsuji O, Adebayo O, Olaopa O, Amoo A, Igbokwe M, Babalola R, et al
. Evaluating the relationship between duty hours and quality of life of nigerian early career doctors. Hosp Top 2020;98:118-126.
Adebayo O, Kanmodi K, Olaopa O, Fagbule OF, Adufe I, Adebayo AM, et al
. Strategies for mitigating burnout among early career doctors in Nigeria: lessons learnt from the qualitative CHARTING study. Glob Psychiatry 2020;3:97-103.
Adebayo O, Ogunsuji O, Olaopa O, Kpuduwei S, Efuntoye O, Omotayo FF, et al
. Trainees collaboratively investigating early career doctors' themes: a NARD initiative in Nigeria. NJM 2019;28:93-97.
[Table 1], [Table 2]