Surgical training exposure and perceived competence in basic surgical skills among final-year medical students in Southwest Nigeria: a multi-institutional cross-sectional study

¹College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria, ²Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Sagamu, Ogun, Nigeria, ³College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun, Nigeria, ⁴Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

^&Corresponding author
Ehikhametalor Jared Oseghale, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria

Introduction    

Instruction in practical procedures and surgical techniques is a core component of undergraduate medical education [1]. High-quality surgical education depends on the development of a defined set of competencies that integrate knowledge, technical skills, and professional attitudes [2]. Global standards, such as those of the World Federation for Medical Education, advocate the integration of procedural skills training in the early stages of medical training [3]. More broadly, simulation-based education has been associated with improved learner confidence in clinical practice [4]. The traditional apprenticeship model, captured in the aphorism "see one, do one, teach one," has been widely criticised as being insufficient for contemporary surgical practice [5]. In many Nigerian medical schools, basic surgical skills continue to be taught largely through bedside teaching, didactic lectures, tutorials, and observation in the operating room, with little or no hands-on operative experience [6]. Many Nigerian graduates therefore enter housemanship with limited practical exposure and are expected to acquire basic surgical skills during their internship [7]. The absence of formal mentorship programmes, poorly equipped skills laboratories, and unequal access to surgical cases compound these curricular limitations [8]. Conversely, early and well-organised skills training has been shown to improve technical proficiency, procedural confidence, and attitudes towards surgical careers [9].

Evidence from sub-Saharan Africa on what undergraduates actually experience remains limited, and few studies have been designed to compare institutions. Single-centre audits in Nigeria and Zambia have documented poor exposure to basic procedures, the latter also demonstrating a positive correlation between clinical experience and self-perceived competence [10,11]. A survey of four state-owned faculties in Cameroon found self-reported confidence to be highest for surgical scrubbing and lowest for manual knot tying, and reported significant differences between faculties in adequate exposure for most of the procedures assessed [12]. A national survey of recent Nigerian graduates similarly found procedural exposure and confidence to be low, with urethral catheterization ranked highest and incision and drainage considerably lower, but compared respondents by institution type and geopolitical zone rather than by individual school [13]. Among postgraduate trainees, these deficits persist into internship, where work fatigue, inadequate mentorship, and the absence of structured skills courses are the barriers most frequently reported [7,14]. To our knowledge, no study in Southwest Nigeria has yet measured surgical training exposure and perceived competence across multiple institutions using a single instrument and a common analytical approach, which is the comparison required if variation between medical schools is to be observed rather than assumed. This study assessed the self-reported competence in basic surgical skills and the extent of exposure to those skills among final-year medical students in Southwest Nigeria and examined the relationship between exposure and perceived competence.

Methods     

Study design and setting: this analytical cross-sectional study was conducted among final-year medical students in seven accredited medical schools in Southwest Nigeria between 9 May 2025 and 28 March 2026. Southwest Nigeria comprises the states of Ekiti, Lagos, Ogun, Ondo, Osun, and Oyo, and contains 13 of the country's 42 accredited medical schools. Undergraduate medical education in Nigeria has its origins in the British medical education system and generally follows a similar six-year structure, leading to the MBBS or MBChB degree over six years, comprising preclinical and clinical phases that include core training in surgery [15].

Study population: eligible participants were students enrolled in a fully accredited medical school in Southwest Nigeria who were in their final clinical year and had completed their senior surgery rotation, as these students were expected to have the experience necessary to respond to the questionnaire meaningfully. Students in preclinical years, clinical students not in their final year, and those who declined consent were excluded from the study.

Sample size: the minimum sample size was calculated using Cochran's formula,

with Z = 1.96, a margin of error of 5%, and p = 0.86, the proportion of students reporting comfort with surgical scrubbing in a comparable study [12]. The initial Cochran estimate was 185. Applying a finite population correction for the 659 eligible final-year students across the seven selected schools reduced the minimum to 145, and the addition of 10% for non-response gave a minimum of 160 participants. A total of 222 eligible students completed the questionnaire and were included in this analysis.

Sampling technique: a multistage sampling technique was employed. In the first stage, one accredited public medical school was selected from each of the six states of Southwest Nigeria by simple random sampling using a ballot to ensure geographical representation of the schools. In the second stage, one accredited private medical school was selected from the eligible private institutions in the region using the same method, giving seven participating schools comprising six public and one private institution. In the third stage, all eligible final-year students from the selected schools were invited to participate. Access was facilitated by the Southwest regional and institutional chapters of the Nigerian Medical Students' Association, whose leaders served as liaisons for distributing the questionnaire. A minimum target of 23 completed questionnaires per institution was set, and recruitment continued for the duration of the study.

Data collection: data were collected using a pretested, self-administered, structured, closed-ended questionnaire administered in English and developed following a review of relevant studies [9,10]. The questionnaire comprised three sections. Section A recorded the participants´ socio-demographic and background characteristics: age, sex, medical school, reported exposure to a school-organised surgical skills workshop, attendance at a surgical skills workshop outside the medical school, future career interest. Section B assessed surgical training exposure across ten skills and procedures, each rated on a four-point scale (0 = never, 1 = observed only, 2 = performed with supervision, 3 = performed independently; composite range 0-30). Section C assessed perceived competence in nine skills, each rated on a five-point scale (1 = not confident at all to 5 = extremely confident; composite range 9-45) in response to the question "How confident are you in your ability to perform the following skills on a real patient (if permitted)?". The item on school-organised workshops asked whether the respondent's medical school had organised such a workshop, and is therefore reported throughout as reported exposure to a school-organised workshop rather than as personal attendance. The questionnaire was pretested among medical students at the Lagos State University College of Medicine (LASUCOM), Lagos. The pretest assessed the clarity, comprehensibility, and appropriateness of the questionnaire items and informed necessary modifications before full deployment. The final questionnaire was administered using Google Forms and distributed through institutional medical students´ association contacts and social media platforms, including WhatsApp. The form was configured to accept only one submission per participant.

Data analysis: data were exported from Google Forms, cleaned, and analysed using SPSS version 27.0 and Python (SciPy, statsmodels, pingouin, and scikit-posthocs). Socio-demographic variables were summarised as frequencies and percentages. Internal consistency of the surgical training exposure and perceived competence scales was assessed using Cronbach's alpha, supported by corrected item-total correlations and alpha-if-item-deleted statistics. Composite scores for both scales were computed by summation and treated as continuous variables. Normality of the composite scores was assessed using the Shapiro-Wilk test and guided their descriptive presentation. Normally distributed composites were summarised using mean and standard deviation, whereas non-normally distributed composites and individual ordinal items were summarised using median and interquartile range. For consistency across outcomes and because several comparison groups were small or unequal in size, between-group comparisons of composite scores were performed using non-parametric tests. Composite scores were compared across categorical independent variables using the Mann-Whitney U test for two-group comparisons, with rank-biserial correlation reported as the effect size, and the Kruskal-Wallis test for comparisons involving more than two groups. Where the Kruskal-Wallis test was significant, pairwise post-hoc comparisons were performed using Dunn's test with Bonferroni correction for multiple comparisons. Associations of age with surgical training exposure and perceived competence, as well as the association between surgical training exposure and perceived competence, were examined using Spearman's rank correlation. Independent predictors of perceived competence were identified using multivariable linear regression, with unstandardized coefficients (B), 95% confidence intervals, and p-values reported. Because participants were recruited within medical schools, medical school was considered as a potential source of institutional variation in the analysis. Medical school and future career interest were evaluated as candidate predictor blocks using nested-model F tests and were retained only where they significantly improved model fit. Bivariate comparisons were pre-specified and hypothesis-driven, and no family wise correction was applied beyond the Bonferroni-adjusted post-hoc tests described. Statistical significance was set at p < 0.05 throughout the study, and there were no missing data for any analysed item.

Ethical considerations ethical approval was obtained from the Health Research and Ethics Committee of Lagos University Teaching Hospital (approval number ADM/DSCST/HREC/APP/7762). The first page of the online questionnaire provided a clear explanation of the study´s purpose and procedures, and completion of the survey was taken as informed consent. Participation was entirely voluntary, with no coercion or incentives, and participants could withdraw at any time before submission without penalty. The questionnaire did not collect personal identifiers, and responses could not be linked to individual participants.

Results     

Characteristics of participants: a total of 222 final-year medical students from seven medical schools completed the questionnaire, with no missing data on any analysed item. The median age was 24 years (interquartile range 24-25, range 20-34), and 137 students (61.7%) were male. The number of participants per school ranged from 27 to 42. A school-organised surgical skills workshop was reported by 124 students (55.9%), while 20 (9.0%) had attended a surgical skills workshop outside their medical school. Eighty-one students (36.5%) intended to pursue a surgical specialty, 58 (26.1%) a non-surgical specialty, and 83 (37.4%) were undecided. Full participant characteristics are presented in Table 1.

Surgical training exposure and perceived competence by skill: the exposure scale demonstrated good internal consistency (Cronbach´s alpha = .827). The composite exposure score was approximately normally distributed, with a mean of 14.82 (standard deviation 5.05) out of a maximum of 30, corresponding to less than half of the maximum attainable score. One item, plaster of Paris application, showed a comparatively low corrected item-total correlation (r = .297) but was retained because it was considered clinically relevant to basic surgical skills. The competence scale demonstrated excellent internal consistency (Cronbach´s alpha = .888, all corrected item-total correlations > .49). The composite competence score was not normally distributed, with a median of 25.0 (interquartile range 19.0-30.0) out of a maximum attainable score of 45. Item-level distributions for both scales are shown in Table 2. Independent performance was reported most frequently for hand scrubbing (39.2%), urethral catheter insertion (35.6%), and aseptic gowning and gloving (24.8%), and least frequently for incision and drainage of abscesses (1.8%), nasogastric tube insertion (4.1%), and wound dressing (6.8%). For incision and drainage of abscesses, 68.5% of students had only observed the procedure and a further 22.1% had never encountered it. Perceived competence followed a similar pattern: 54.1% of students were very or extremely confident in urinary catheterization and 49.1% in hand scrubbing, compared with 10.8% for minor surgical procedures such as incision and drainage, 12.2% for plaster of Paris application, 14.9% for knot tying, and 19.8% for basic suturing.

Comparisons across sociodemographic and institutional factors: surgical training exposure did not differ by sex (median 15.0, interquartile range 11.0-18.0 in males vs. 15.0, 12.0-18.0 in females; U = 5593.5, p = .623, r = -.039) or future career interest (H = 1.824, df = 2, p = .402), and age was not significantly correlated with exposure (Spearman´s rho = .032, p = .638). Perceived competence likewise did not differ by sex (U = 5873.0, p = .914, r = .009) or future career interest (H = 4.114, df = 2, p = .128), and was not significantly correlated with age (Spearman´s rho = .054, p = .423). Students who reported that their school had organised a surgical skills workshop had higher exposure (median 17.0, interquartile range 13.0-20.0 vs. 13.0, 10.0-16.0; U = 8290.0, p < .001, r = .364) and higher perceived competence (27.5, 22.8-32.0 vs. 21.0, 17.0-27.0; U = 8820.0, p < .001, r = .452) than those who did not. Attendance at a surgical skills workshop outside the medical school was not associated with exposure (15.5, 11.0-17.5 vs. 15.0, 12.0-18.0; U = 2083.0, p = .819, r = .031) but was associated with higher perceived competence (28.0, 24.0-32.0 vs. 24.5, 19.0-30.0; U = 2563.5, p = .047, r = .269).

Predictors of perceived competence: surgical training exposure was strongly and positively correlated with perceived competence (Spearman´s rho = .652, p < .001). In the multivariable linear regression model (R²= .472, adjusted R². = .459; F(5,216) = 38.55, p < .001), greater exposure remained independently associated with higher perceived competence (B = .829, 95% confidence interval .684-.973, p < .001). Reported exposure to a school-organised workshop (B = 3.041, 95% confidence interval 1.548-4.533, p < .001) and attendance at a workshop outside the medical school (B = 2.688, 95% confidence interval .223-5.154, p = .033) were also independently associated with higher perceived competence. Sex and age were not significant predictors (Table 3). Medical school and future career interest were evaluated as candidate predictor blocks but did not significantly improve model fit and were not retained. Multicollinearity was assessed using variance inflation factors and the normality of residuals using the Shapiro-Wilk test; both assumptions were satisfied.

Differences between medical schools: both outcomes differed significantly across the seven medical schools (exposure H = 51.65, df = 6, p < .001; perceived competence H = 49.63, df = 6, p < .001). Median exposure ranged from 11.0 to 18.0 out of 30, and median perceived competence from 18.0 to 30.0 out of 45 (Table 4). Bonferroni-adjusted Dunn´s post hoc comparisons showed that the University of Ibadan, the University of Lagos, and Obafemi Awolowo University each scored significantly higher than Olabisi Onabanjo University and the University of Medical Sciences, Ondo on both outcomes (all adjusted p < .01). Bowen University scored significantly higher than the University of Medical Sciences, Ondo on exposure (p = .041) and than Olabisi Onabanjo University on perceived competence (p = .034). Ekiti State University did not differ significantly from any other school on either outcome.

Discussion     

Statement of principal findings: this study aimed to determine whether the exposure that final-year medical students actually receive is associated with their perceived competence in basic surgical skills. Greater exposure remained independently associated with higher perceived competence after adjustment, while age, sex, and intended career path were unrelated to either exposure or competence. Together, these findings suggest that the institutional training environment may contribute substantially to differences in perceived preparedness. Two further patterns support this interpretation. First, exposure and confidence were consistently highest for procedures that are commonly performed by students in clinical practice, such as scrubbing and catheterization, and lowest for those thought to require greater technical proficiency, such as knot tying, suturing, and incision and drainage of abscesses. This pattern suggests that students are more frequently exposed to tasks that can be readily delegated than to procedures requiring deliberate acquisition of technical skills. Second, both outcomes varied substantially between medical schools, and the schools with the lowest exposure were also those with the lowest perceived competence. These institutional differences may partly reflect variation in training opportunities.

Strengths of the study: the main strength of this study is its multi-institutional design. Sampling six public and one private medical school across six states allowed comparison of institutional variation, which single-centre studies cannot. The invitation was extended to all final-year students at each school rather than a convenience sample, there were no missing data for any analysed item, and both scales showed good to excellent internal consistency. Effect sizes were reported for all bivariate comparisons, post hoc tests were corrected for multiple comparisons, and regression assumptions were formally assessed.

Strengths in relation to other studies: the principal strength of this work relative to existing evidence is its multi-institutional undergraduate design. Comparable African studies have been single-centre [6,10,11] or have sampled postgraduate trainees rather than students [7,14], and the one national survey addressing undergraduate exposure did so by questioning recent graduates, comparing them by institution type and geopolitical zone rather than by individual school [13]; among the studies available, only the Cameroonian survey of four state-owned faculties examined students at more than one school while they were still in training [12]. In the present study, one public school in each of the six states and one private school in the region were selected by simple random sampling, and all seven were surveyed using a single instrument and a single analytical framework, reducing the possibility that observed differences between schools reflect variation in item wording or scoring. Exposure and competence were measured as composite scales of demonstrated internal consistency and were then modelled against one another with adjustment for student-level characteristics, whereas the multi-institutional studies reported the two constructs separately without modelling one against the other [12,13], and the studies that did quantify the association examined either a single institution [11] or postgraduate trainees [14].

Discussion of important differences in results: two findings diverged from expectations. We found no statistically significant sex differences in either exposure or perceived competence. Concerns about differential access to operative opportunities are frequently raised in surgical education, but systematic review evidence indicates that objectively measured technical performance does not differ meaningfully between male and female trainees [16]. The present finding is consistent with this evidence. The findings suggest no detectable sex difference in undergraduate exposure in this sample, although smaller differences or sex-related barriers cannot be excluded. This should be interpreted as a finding about undergraduate exposure specifically, and not as evidence that sex-related barriers are absent from later stages of surgical training. The second concerns the two workshop variables, which differ in an instructive way. Attendance at a workshop outside the medical school was an individual-level exposure and was independently associated with competence, whereas reported exposure to a school-organised workshop was inseparable from the institution attended. Provision ranged from approximately one-tenth to all respondents across the seven schools; thus, the two variables carry largely the same information. The appropriate interpretation is that structured training is associated with greater competence, but this study cannot establish whether the association derives from the workshop itself or from the broader teaching environment of the schools that provide one. This distinction is easily lost in the literature, where workshop provision and institutional quality are seldom separated.

Meaning of the study: given the observed association between exposure and perceived competence, improving surgical preparedness should include institutional and quality-assurance approaches to strengthen structured, hands-on training. The traditional apprenticeship model, in which competence is expected to accrue through observation, appears insufficient in a setting where students observe far more often than they perform [5]. Structured skills training offers a practical remedy that does not depend on increased patient volume: simulation-based instruction can improve procedural confidence and performance in medical students [17], is feasible and effective in sub-Saharan African settings [18], and can be delivered by trained peers or near-peers where faculty capacity is limited [17]. Early structured exposure has also been shown to improve both skill acquisition and attitudes towards surgical careers [6,9]. Three implications for practice and policy follow. Skills training should be timetabled rather than optional; it should be targeted at the procedures for which students reported the lowest exposure and perceived competence rather than distributed evenly; and minimum exposure benchmarks should be defined and monitored, since the variation observed between institutions is a quality assurance concern that individual students cannot remedy. Strengthening formal mentorship would complement these measures, given its recognised role in structuring surgical skill development [8].

Unanswered questions and future research: three questions follow directly from this work. The first is whether perceived competence corresponds to demonstrated competence in this population; studies pairing self-report with objective assessment, such as the Objective Structured Assessment of Technical Skills, are needed to establish how far the present estimates can be trusted. The second is whether the associations reported here are causal. Only longitudinal or interventional designs can establish whether expanding structured training improves competence, and whether any gains persist into internship and early postgraduate practice. The third is what specifically differs between the higher- and lower-performing institutions identified here. This study demonstrates that schools differ but cannot say why, and identifying the responsible curricular, staffing, and infrastructural factors is a prerequisite for targeted intervention rather than general exhortation. Extending this work to other geopolitical zones would establish whether these patterns are regional or national, and repeating it after any curricular reform would provide a means of evaluating whether such reform has achieved its intended effect.

Limitation: this study has several limitations. First, surgical training exposure and perceived competence were both self-reported, and competence was not objectively assessed; common-method bias may therefore have inflated their association. Second, the cross-sectional design precludes causal inference. Third, participation was voluntary, and the questionnaire was distributed through student-association channels; the number of eligible students who received the invitation could not be verified, so no response rate could be calculated, and self-selection is possible. If students with greater interest in surgery, greater prior surgical exposure, or higher perceived competence were more likely to participate, the overall exposure and competence estimates may have been overestimated. Because the number and characteristics of non-participants were unavailable, the magnitude of this potential bias cannot be quantified. Fourth, only 20 participants reported attendance at a surgical skills workshop outside the medical school, limiting the precision of that estimate. Fifth, reported exposure to a school-organised workshop was strongly patterned by institution, preventing separation of the workshop association from broader school-level differences; consequently, the workshop coefficient may partly reflect other institutional characteristics. Finally, the study was confined to final-year students in one geopolitical zone, limiting generalisability to students in other clinical years and regions of Nigeria.

Conclusion     

Final-year medical students in participating medical schools in Southwest Nigeria reported limited hands-on surgical exposure, with lower perceived competence for several procedures including minor surgical procedures, plaster of Paris application, knot tying, and basic suturing. Greater exposure was independently associated with higher perceived competence, while differences between medical schools suggest an important role for institutional factors. Medical schools should strengthen structured, hands-on and simulation-based surgical skills training and establish minimum exposure standards to improve preparedness for clinical practice.

Competing interests     

The authors declared no competing interests.

Authors' contributions     

Ehikhametalor Jared Oseghale: conceptualization, methodology, investigation, writing - original draft, writing - review and editing, interpretation of findings. Arinze Kingsley Ngwu: conceptualization, methodology, formal analysis, writing - original draft, writing - review and editing, interpretation of findings. Adedeji Fathy Adeleke: investigation, writing - review and editing. Ayomikun Joseph Adu: investigation, writing - review and editing. Temitayo Femi Matthew: investigation, writing - review and editing. Olumide Abiodun Elebute: methodology, writing - review and editing, interpretation of findings. All the authors have read and approved the final version of this manuscript.

Acknowledgments     

The authors thank the Southwest regional and institutional chapters of the Nigerian Medical Students' Association for facilitating access to the participating medical schools, the student liaisons at each institution for coordinating questionnaire distribution, and all final-year medical students who took the time to participate in this study. Generative AI disclosure: OpenAI ChatGPT was used to assist with language editing, manuscript formatting, and verification of statistical calculations during manuscript preparation. All outputs were critically reviewed and verified by the authors, who take full responsibility for the accuracy, interpretation, originality, and integrity of the final manuscript.

Tables     

Table 1: distribution of sociodemographic characteristics, surgical skills workshop exposure, and future career interest among final-year medical students in seven selected medical schools in Southwest Nigeria, May 2025 - March 2026 (N = 222)

Table 2: distribution of self-reported surgical training exposure and perceived competence across individual basic surgical skills among final-year medical students in seven selected medical schools in Southwest Nigeria, May 2025 - March 2026 (N = 222)

Table 3: multivariable linear regression analysis of factors associated with perceived competence in basic surgical skills among final-year medical students in seven selected medical schools in Southwest Nigeria, May 2025 - March 2026 (N = 222)

Table 4: distribution and comparison of surgical training exposure and perceived competence scores by medical school among final-year medical students in seven selected medical schools in Southwest Nigeria, May 2025 - March 2026 (N = 222)

References