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Skills, Education, Operating room, Qualitative research, IntroductionSurgical residents often experience a tense environment in training arenas ( 1, ). Their training in operating rooms faces several challenges, including a decline in academic records compared to the last century, demographic changes, economic constraints, and changes in attitudes toward surgery training, with an emphasis on patient safety ( 2, ). The number of open surgical procedures is declining, and they are abandoned in some cases, so the residents&apos, opportunity to gain experience and practice has reduced or removed. On the other hand, the number of complex endoscopic and laparoscopic interventions is increasing ( 3, ). The introduction of less invasive technologies and, consequently, the&,nbsp possibility of different endoscopic interventions over the past two decades has challenged the training and evaluation of surgical residents ( 4, ). Research studies also show that some surgical residency graduates do not have the necessary qualifications ( 5, ). Researchers believe that traditional surgery training with senior/junior hierarchy in relationships cannot meet the need for learning complex technical skills in today&apos,s operating room, in a constrained period of residency training. The atmosphere of apprehension in the signor/junior residency training system for surgical residents causes rejection, resentment, and severe stress, which affect their learning ( 6, ). In 2019, the American Society of Surgeons emphasized the necessity of adjustments in this training environment. According to the statement, harassment, coercion, and discrimination are three distinct interpersonal behaviors that can negatively affect professional relationships, job satisfaction, and physical/mental health. In addition to&,nbsp threatening the health of employees, these behaviors create a hostile work environment that can endanger the safety of patients ( 7, ). Therefore, the improvement of this educational arena, development of constructive communication, and creation of an interactive educational environment are emphasized ( 8, ).On the other hand, training courses and working hours of residents have been affected by the financial issues of hospitals and economic pressures prevailing in medical centers ( 9, ). As future health care practitioners, the better they are trained with opportune planning and practical training in a proper context, the more qualified employees would be to provide high-quality services ( 10, ). Over the past few decades, the development of structured and efficient approaches to surgical courses, including attention to setting primary educational goals, efficient evaluation methods based on receiving feedback, and the use of effective teaching models has been highly emphasized ( 11, ). In this regard, several educational models, including the Zwisch model, which provides both faculty and residents with specific stages of supervision, allow for adequate, safe training in a graduated manner to develop operative autonomy and fully trained surgeons. The other excellent model is Briefing-Intraoperative-Debriefing (BID) model that walks the learner through the surgery in three stages. During the briefing stage, the attending surgeon starts the conversation with a brief question about the goal of the operation or previous experiences. In the intraoperative stage, the attending surgeon will still coach and guide the resident through the operation and, finally, in the debriefing stage, the preceptor and learner debrief about the encounter. Also, assessment tools such as Objective Structured Assessment of Technical Skills (OSATS) are widely used to score the skills of each surgical trainee in performing or assisting in real operations. Similarly, Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) is a 9-item surgical evaluation tool designed to assess technical competence in surgical trainees using behavioral anchors ( 12, - 15, ). However, in many operating rooms, surgical residency training is still performed in a challenging and stressful environment, based on the lecturer-student model in which residents must learn in a competitive situation through observation and by watching the performance of instructors or senior residents, performing the procedure under the supervision of senior residents, and eventually teaching junior residents during their residency course ( 16, ). In this learning framework, they try to fulfill the assigned&,nbsp responsibilities of patient safety by adopting coping strategies in different encounters and avoiding conflicts, and at the same time, improving their surgical skills ( 17, ). Since there was no accurate information on the challenges and strategies used by surgical residents in operating rooms, the present qualitative study was conducted through in-depth semi-structured interviews with the purpose of the explanation of surgical residents&apos, experience in the acquisition of surgical skills.MethodsThe present study is a qualitative, conventional content analysis with the purpose of explanation of surgical residents&apos, experience in surgical skills acquisition in operating rooms.The study settings were 11 academic hospitals in 8 cities of Iran, including Tehran, Karaj, Ardabil, Rasht, Qazvin, Tabriz, Shiraz, and Mashhad.Resident participants in this research were selected based on the study purpose and maximum diversity in academic records, gender, age, and university/medical college where they were training. The inclusion criteria of the study were continuous participation in practical residency courses in the operating room for at least six months and consent to participate in interviews. Eligible participants entered the study after discussing the study objectives&,nbsp and oral consent. We determined the number of required respondents by interviewing the residents who met the inclusion criteria until the data were saturated, and no new topics were generated. The saturation was achieved at the 25th interview.The research data were collected through in-depth semi-structured interviews with 25 surgical residents. The interviews were conducted in person in the operating rooms and residents&apos, pavilion, or pre-planned online interviews through WhatsApp. The interviews began with a sample of the following general questions for a mean of 30 to 45 minutes per session. Explain your training day in the operating room? What is your opinion about the general surgery program? How do your training and evaluations direct you to higher levels? Then, based on the participant&apos,s answers, provocative or exploratory questions were asked to deepen the interview. For example, Can you give us more details? Please give an objective example of what you just said. How did you feel then? &,nbsp After the 25th interview, the data was saturated, and no new information was added.The data analysis process was performed using conventional content analysis methods in three phases, preparation, organization, and reporting ( 18, ). In the preparation phase, immediately after each interview session, the recorded content was accurately transcribed in detail and entered the MaxQDA software to facilitate the analysis process. Then, each interview was read several times during the organization phase. After repeated readings, semantic units related to the research question were selected, and the initial open codes were written for them. Three hundred ninety-eight open codes were extracted. Similar open codes were classified into a subcategory in terms of notion and meaning. Using constant comparison methods in the last stage of the data analysis, similar items were merged, and the main categories were identified to explain the surgical residents&apos, experience in the acquisition of surgical skills in operating rooms.Trustworthiness and Consistency, We used Cuba and Lincoln&apos,s five criteria of credibility, transferability, dependability, authenticity, and conformability to strengthen the data ( 19, ).To verify the raw data, the transcribed interviews were sent to the participants via email or WhatsApp. Recording reminders and notes in the field, emphasis on sampling with maximum variability (age, sex, marital status, operating rooms in different colleges, different years of residency), and peer review were among the researchers&,rsquo measures to ensure the validity of the study. Undoubtedly, the researcher&apos,s disposition in teaching and research in the field of medical education and the operating room also contributed to the theoretical sensitivity and validity of the study.Ethical ConsiderationsThe present research is based on the results of a doctoral dissertation approved by the ethics committee of Shahid Beheshti University of Medical Sciences with IR.SBMU.SME.REC.1398.057 moral license number.With respect to principles of research ethics, all research participants gave their consent, they were assured their data would be kept confidential, and their audio files would be deleted at the end of the study. They were also assured that they were authorized to refrain from participation at any stage of the research process.ResultsThere were 25 participants in the study, including eighteen male residents and seven females. Five of them were in the first year, 5 in the second year, 6 in the third year, 6 in the fourth year, and 3 in the fifth year of their residency course. Sixteen residents were married, and nine were single. The mean age of the male and female participants was 36&,plusmn 3.2 and 32&,plusmn 2.3 years, respectively.&,nbsp The results of common content analysis related to surgical residents&apos, experiences of the clinical training process were categorized into two main categories, challenges /obstacles and strategies for dealing with challenges (Table 1,).Main categorySubcategoryChallenges and ObstaclesBurnoutConfusion in technique selection |