AJHPE Vol 6, No 1 (2014) by HMPG

AJHPE

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African Journal of Health Professions Education

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May 2014, Vol. 6, No. 1

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AJHPE

African Journal of Health Professions Education | May 2014, Vol. 6, No. 1 EDITORIAL 2

Interprofessional education – is it ‘chakalaka’ medicine? V Burch

R ESEARCH 3 The effect of an interprofessional clinical simulation on medical students I Treadwell, M van Rooyen, H Havenga, M Theron 6

Are further education opportunities for emergency care technicians needed and do they exist? C Vincent-Lambert, J Bezuidenhout, M Jansen van Vuuren

10 How we see ‘Y’: South African health sciences students’ and lecturers’ perceptions of Generation Y students L J van der Merwe, G J van Zyl, M M Nel, G Joubert 17 Do physiotherapy students perceive that they are adequately prepared to enter clinical practice? An empirical study H Talberg, D Scott 23 PIQUE-ing an interest in curriculum renewal J Blitz, N Kok, B van Heerden, S van Schalkwyk 28 Student doctors (umfundi wobugqirha): The role of student-run free clinics in medical education in Cape Town, South Africa S C Mendelsohn 33 Problem-solving abilities of radiography students at a South African University T Pieterse, H Lawrence, H Friedrich-Nel 37 Introduction of a learning management system at the Kilimanjaro Christian Medical University College L Killewo, E Lisasi, G Kapanda, D Tibyampansha, G Ibrahim, A Kulanga, C Muiruri, N Fadhili, D Wiener, A Wood, E Kessi, K Mteta, M Ntabaye, J A Bartlett 41 Medical and dental students’ willingness to administer treatments and procedures for patients living with AIDS A Y Oyeyemi, U S Jasper, A Oyeyemi, S U Aliyu, H O Olasoji, H Yusuph 45 Understanding the learning styles of undergraduate physiotherapy students D Hess, J M Frantz 48 Health-promoting schools as a service learning platform for teaching health-promotion skills L M du Plessis, H E Koornhof, L C Daniels, M Sowden, R Adams 52 Using graduates as key stakeholders to inform training and policy in health professions: The hidden potential of tracer studies A G Mubuuke, F Businge, E Kiguli-Malwadde 56 The effect of characterisation training on the congruence of standardised patient portrayals I Treadwell, L Schweickerdt-Alker, D Pretorius, M D Hugo 60 Continuous professional training of medical laboratory scientists in Benin City, Nigeria B H Oladeinde, R Omoregie, I Odia, E O Osakue 64 Physiotherapy clinical students’ perception of their learning environment: A Nigerian perspective A C Odole, N A Odunaiya, O O Oyewole, O T Ogunmola

ABSTRACTS

69 Sixth National Conference of the South African Association of Health Educationalists (SAAHE): ‘Information to Transformation’, Umhlanga, 27 - 29 June 2013

115 CPD QUESTIONNAIRE

AJHPE is published by the Health and Medical Publishing Group (Pty) Ltd Co registration 2004/0220 32/07, a subsidiary of SAMA | publishing@hmpg.co.za 28 Main Road (Cnr Devonshire Hill Road), Rondebosch, 7700 | +27 (0)21 681 - 7200 All letters and articles for publication must be submitted online at www.ajhpe.org.za

EDITORIAL BOARD EDITOR-IN-CHIEF Vanessa Burch University of Cape Town INTERNATIONAL ADVISORS Deborah Murdoch-Eaton Sheffield University, UK Michelle McLean Bond University, QL, Australia SENIOR DEPUTY EDITORS Juanita Bezuidenhout Stellenbosch University Jose Frantz University of the Western Cape DEPUTY EDITORS Jacqueline van Wyk University of KwaZulu-Natal Julia Blitz Stellenbosch University ASSOCIATE EDITORS Francois Cilliers University of Cape Town Lionel Green-Thompson University of the Witwatersrand Dianne Manning University of Pretoria Ntombifikile Mtshali University of KwaZulu-Natal Marietjie Nel University of the Free State Ben van Heerden Stellenbosch University Marietjie van Rooyen University of Pretoria Gert van Zyl University of the Free State

HMPG Editor Janet Seggie Consulting Editor JP de V van Niekerk Deputy Editor Bridget Farham Editorial Systems Manager Melissa Raemaekers Scientific Editor Ingrid Nye Technical Editors Emma Buchanan Paula van der Bijl Head of Publishing Robert Arendse Production Assistant Neesha Hassan Art Director Brent Meder DTP & Design Carl Sampson Anelia du Plessis Online Manager Gertrude Fani ISSN 1999-7639

Editorial Interprofessional education – is it ‘chakalaka’ medicine? In this edition of AJHPE, an article by Treadwell et al.[1] reports on the reflections of 5th-year medical students after participation in an interprofessional learning activity. I was struck by a comment made by one of the students: ‘My biggest challenge was remembering what needs to be done … It was just "chakalaka" and all mixed up.’ So what exactly is multiprofessional/interprofessional education? Put quite simply, it is learning that occurs when two or more professions learn with, from and about each other to facilitate collaboration in practice.[2] Globally, an ageing population and a rapidly rising prevalence of chronic diseases and accompanying disability have resulted in a shift in focus from cure to controlling of symptoms, and maximising patients’ level of functioning and quality of life while helping their families to cope with longterm illness. As a result of the skills and complexity of knowledge required to provide such care, specialisation in the respective healthcare professions is increasing. Given this reality, it is clear that healthcare in the 21st century requires a team approach that calls upon a range of healthcare professionals with the requisite expertise needed to provide comprehensive care. Despite the recognised interdependence of healthcare professionals, the approach to professional licensing remains uniprofessional, resulting in a significant measure of disconnect between pre-registration and postregistration practice where interprofessional care is essential. Therefore, students enter their professional training with preformed and stereotyped perceptions of their profession and negative stereotypes regarding other professions, which leads to professional arrogance that hampers the development of collaborative relationships.[3] Furthermore, there is considerable power in having control over a distinct body of knowledge; this cognitive exclusivity further undermines communication and development of effective relationships between different professions.[4] In traditional models of healthcare, the situation is further exacerbated because doctors usually prescribe the involvement of other healthcare professionals in the patient’s care, which leads to dominance and ineffective communication.[5] Breaking out of this mould and changing the foundation of the relationships between healthcare professionals require radical revision of our teaching practices and student learning activities. While opportunities to engage in interprofessional learning experiences are increasing, they are mainly limited to specific events rather than routine practice. It is therefore not surprising that the students interviewed by Treadwell et al.[1] lacked the appropriate communication and teamwork skills to manage a patient in a multiprofessional setting. The student’s ‘chakalaka’ comment is a powerful statement about the urgent need for large-scale interprofessional training programmes, rather than a few isolated events, to facilitate the development of interprofessional competence. So, where to now? Firstly, social identity theory suggests that group membership is dynamic, context dependent and can shift in order that subgroups broaden their boundaries to regard themselves as members of an inclusive team of healthcare professionals. Several studies have shown that interprofessional education early in undergraduate health professions education leads to better interprofessional communication.[6] Therefore, the first step to remedy the current situation is the introduction of interprofessional learning activities in the early years of undergraduate training programmes. Students need to work together long before they have had time to develop stereotypic approaches towards peers based on ignorance and arrogance. Secondly, the core content of interprofessional education, including the core competencies required for effective teamwork such as respect between

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professionals, learning about professional roles and healthcare systems, leadership, conflict resolution and ethics, has already been outlined by organisations such as the World Health Organization.[7] Undergraduate health professions curricula should include early interprofessional learning with an emphasis on the central values of professionalism (altruism, accountability, excellence, duty, advocacy, service, honour, integrity, respect for others and ethical and moral standards) and the acquisition of skills required for effective functioning in an multiprofessional team. Thirdly, interprofessional practice allows each profession to independently contribute their expertise to the assessment of patients and management decisions. This is best achieved by organising the team around solving a common set of problems where each team member contributes a knowledge and skills set that augments and supports the contributions by others, thereby ensuring holistic management of the patient’s complex health problems. While individual team members preserve their specialised functions, each team member is sufficiently familiar with the concepts and approaches of others so that the roles of team members blur into a common understanding of the patient’s problems and management plan. The preceding discussion suggests that clinician educators need to focus on four key activities when teaching in an interprofessional setting: (i) allow the students to clearly identify the patient’s key clinical problems that require intervention; (ii) ask students to articulate the reasons why a multiprofessional team is required to address the clinical problems identified; (iii) allow each team member to make an independent contribution to addressing the patient’s healthcare needs; and (iv) ensure that the team develops a comprehensive management plan that encompasses all the contributions made by the respective team members. Ultimately, respect for the expertise of each team member and shared decision-making, where the doctor is not dominant, is fundamental to successful interprofessional practice. Undergraduate students from different professsions need broad and frequent exposure to interprofessional patient assessments and role models leading multiprofessional teams where respect, collaboration and shared decision-making can be experienced. Two examples of this model of care include multiprofessional units dedicated to the care of stroke patients, and care of the elderly. Such units could provide an excellent platform for undergraduate training in interprofessional practice. Vanessa Burch

Editor-in-Chief African Journal of Health Professions Education vanessa.burch@uct.ac.za

1. Treadwell I, Van Rooyen M, Havenga H, Theron M. The effect of an interprofessional clinical simulation on medical students. AJHPE 2014;6(1):3-5. [http://dx.doi.org/10.7196/AJHPE.231] 2. Barr H. Interprofessional education: 1997-2000. A review. UK Centre for the Advancement of Interprofessional Education (CAIPE) 2000. http://www.caipe.org.uk (accessed 2 May 2014). 3. Boaden N, Leaviss J. Putting teamwork in context. Med Educ 2000;34:921-927. 4. Hammick M. Interprofessional education: Concept, theory and application. J Interprof Care 1998;12:323-332. 5. Atwal A, Caldwell K. Do all health and social care professionals interact equally: A study of interactions in multidisciplinary teams in the United Kingdom. Scand J Caring Sci 2005;19:268-273. 6. Horak BJ, O’Leary KC, Carlson L. Preparing health care professionals for quality improvement. The George Washington University George Mason University experience. Qual Manag Health Care 1998;6:21-30. 7. World Health Organization. Learning Together to Work Together for Health. Report of a WHO Study Group on Multiprofessional Education of Health Personnel: The Team Approach. Technical Report No. 769. Geneva: World Health Organization, 1988.

AJHPE 2014;6(1):2. DOI:10.7196/AJHPE.424

Research The effect of an interprofessional clinical simulation on medical students I Treadwell,1 DCur, HED; M van Rooyen,2 MMed (Fam Med), MB ChB; H Havenga,1 ILS practitioner; M Theron,1 MSocSc 1

Skills Centre, Faculty of Health Sciences, University of Limpopo (Medunsa Campus), Pretoria, South Africa

Department of Family Medicine, University of Pretoria, South Africa

Corresponding author: I Treadwell (ina.treadwell@ul.ac.za)

Background. Teamwork as an outcome for graduates implies the understanding and appreciation of the roles, responsibilities and skills of other professions. An interprofessional education (IPE) event was initiated as a simulated management of a multiply traumatised patient in the acute phases of his injury, relevant to both medical and nursing students. The objective was to explore medical studentsâ&#x20AC;&#x2122; reflections on the value of this clinical simulation. Method. A mixed-methods study was done, using a convenience sample of 5th-year medical students (N=96). Participants wrote a multiple-choice question (MCQ) test and either actively participated in the simulation or observed the actions through a one-way mirror. The simulations were facilitated by experienced skills trainers. On completion, the participants repeated the MCQ test and took part in a facilitator-led debriefing. The latter was audiotaped and students could submit written reflections. Written comments and transcripts of the audiotapes were analysed thematically. Results. Participantsâ&#x20AC;&#x2122; average test scores improved significantly (p<0.001) from 63.5% before the simulation to 68.6% thereafter. Five themes emerged from the reflections: (i) difficulties with implementing knowledge and skills; (ii) importance of teamwork; (iii) skills necessary for teamwork; (iv) effect of being observed by peers; and (v) IPE in the curriculum. Conclusions. Medical students gained clinical knowledge during the simulation and became aware of their lack of skills, knowledge, and opportunities to acquire and practise skills required for effective teamwork. AJHPE 2014;6(1):3-5. DOI:10.7196/AJHPE.231

Interprofessional education (IPE) emphasises interactive learning with and from members of other professions, aimed at improving patient care.[1] Interdependence in education and the understanding and appreciation of the roles, responsibilities and skills of other care workers are vital to strengthen health systems.[2] It has been advocated that an interprofessional approach should be integrated in the education of health professionals[1] to contribute to overcoming difficulties in communication and teamwork in care services, as well as helping to change attitudes and reduce stereotyping between professional groups.[3] Despite increased recognition and a variety of initiatives, projects and events, and a sentiment that things are headed in the right direction,[4] many healthcare professionals enter practice without sufficient training in the delivery of interprofessional care.[2] The learning outcomes extend across the range of relevant knowledge, skills and attitudes deemed necessary for confidence and capability in the practice of collaborative care.[5] By participating in collaborative care activities, students are challenged to interpret what happened and construct meaning through their personal experience. This new construct of meaning is then incorporated into the studentâ&#x20AC;&#x2122;s existing knowledge.[6] The context for clinical education can be created in a simulation exercise with a safe, structured and supportive environment that links the lecture room and clinical practice.[5] A simulation also seems to have a beneficial effect on the acquisition of technical skills, the development of higher cognitive skills such as clinical reasoning and decision making, analytical and communication skills, and on psychomotor and procedural skills.[7] As trauma resuscitations require a co-ordinated response from a diverse group of healthcare providers and form part of the curricula of a variety of professions, it was decided to create an IPE event that reflects the reality

of a traumatised patient during the acute phase of his injury. The focus of this one-time event was on short-term outcomes such as clinical skills, knowledge and attitudes required for shared management of a traumatised patient.

Aim

The aim of this study was to explore the effect of an interprofessional clinical simulation on medical students.

Method

A mixed-methods study was done on the effect of interprofessional clinical simulation on medical students at the Medunsa Campus Skills Centre of the University of Limpopo, 25 km north-west of Pretoria, South Africa. The following tools were developed and reviewed by the medical and nursing lecturers from the Skills Centre: (i) a 20-item multiple choice question (MCQ) test related to trauma management, validated by five lecturers involved in clinical simulation; (ii) a scenario for the simulation of the management of a multiply traumatised patient; and (iii) a guidance and assessment tool, based on a theoretical and skills competency framework for students of both professions, to determine the outcomes, responses, and actions, and the required equipment. Ethical permission was obtained from the Medunsa Research and Ethics Committee. The simulation comprised two acute phases: The pre-hospital phase: A standardised patient (SP) portrayed a 25-yearold technician who had been working on the roof of the Skills Centre when his screwdriver fell and rolled away. He managed to grab the screwdriver but lost his balance and fell about 6 m from the roof. He sustained injuries to his chest and a stab wound to his right arm. Students were expected to provide emergency care and transport the patient to the emergency room.

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Research The initial in-hospital phase: The SP was replaced by a high-fidelity simulator to simulate difficulty in breathing due to a pneumothorax as well as a deep stab wound to his right upper arm. Students had to provide initial emergency care as a team.

made summative notes of the verbal and non-verbal communications and their personal experiences. These notes were compared and discussed and the corresponding items of information were grouped together and organised in themes. The following five themes emerged:

Sample

Theme one: Implementation of knowledge and skills Participants experienced difficulty in translating theory into practice during the simulation. Some factors contributing to erring, such as not noticing the patient’s level of consciousness decreasing, may have been the added pressure of performance, time limitation due to the reality of dealing with a dying patient, lack of structure in their thought processes, and realising possible lack of long-term retention of studied material. ‘It’s tougher than you think, because someone is crashing there, the blood pressure is going down and you think you’re losing the person and your mind slips.’ ‘My biggest challenge was remembering what needs to be done … , everything just comes and comes. It was just "chakalaka" [spicy South African vegetable relish] and all mixed up.’ ‘I realised that in order for one to be perfect, one needs to practise, practise and practise. The theory is there, but application is confusing.’ ‘Overwhelming, you try to remember stuff that you learnt, but it was not coming.’ They also realised that their skills needed some practice and appreciated the opportunity to practise in a safe invironment: ‘Rather make mistakes on something that is not living than killing someone inadvertently in casualty. I would have made these mistakes and the patient would have died.’

Attending the simulation was mandatory for 5th-year medical students (N=120). Those who were willing to participate in the study signed an informed consent form and became the convenience sample (n=96), i.e. the participants. Fourth-year nursing students (N=39) were also invited to join the exercise. Sixteen students consented, but withdrew from the study before participating in the simulation. Both student groups had already completed lectures on trauma in their respective curricula and had acquired psychomotor skills in the Skills Centre required to manage a traumatised patient.

Pre-simulation

Both student groups were orientated in class on what was expected of them in the simulation, using a video featuring the facilitators resuscitating the ‘patient’. After signing consent forms the participating students wrote the MCQ test.

Simulation

As there were many students and only three afternoons available, the simulation was duplicated in concurrently running sessions. The students were divided into six groups of about 25 students. Three medical students and one nursing student from each group were invited to take part in the simulated resuscitations, while the rest observed, guided by a checklist, through one-way mirrors. The team was expected to manage the patient’s airway and assess his breathing, oxygen saturation, blood pressure as well as levels of consciousness and pain. They had to administer oxygen, stabilise the cervical spine with head blocks, obtain a history, do a full secondary assessment to identify the simulated injuries, insert two intravenous lines, perform a needle decompression of the chest, suture the laceration on his arm, assess the distal pulses and motor function, pass a urinary catheter and insert a nasogastric tube. Students also had to provide information to and comfort the patient throughout. At this stage the nursing students withdrew from the study and were replaced by newly registered nurses. The simulations were facilitated by teams of experienced medical, nursing and paramedic skills trainers. On completion of the simulation, the participants repeated the MCQ test and took part in a facilitator-led debriefing that was audiotaped. They also completed a post-simulation questionnaire on readiness for IPE and perceptions of their own and other professions. The findings and written comments on the post-simulation questionnaire will be reported in a separate paper. The comments and transcripts of the debriefing audiotapes were individually analysed by three researchers who reached consensus on five themes and used verbatim quotations to illustrate some of the respondents’ views.

Results

The average percentages for the pre- and post-simulation MCQ tests were calculated and compared using the McNemar test.[8] The mean score for the post-simulation test (68.6%) was significantly (p<0.001) higher than that for the pre-simulation test (63.5%). Qualitative content analysis was done on the optional written comments on post-simulation questionnaires and the audiotapes of the post-simulation debriefing. The four researchers

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Theme two: Importance of teamwork Participants reported the following: • a clearer understanding of the nurses’ scope of practice: ‘I did not realise that she [nurse] could suture the arm … ’ ‘They [nurses] are very capable of taking care of a patient, even more than I and have lots of advice to give and experience to share.’ • that teamwork provides a platform to share ideas, exchange information and learn from one another: ‘ … other professions are as important as mine and I must trust their judgement and be open minded to learn from them.’ • their understanding that a team doesn’t function effectively if team members do not trust, appreciate and respect each other: ‘I learned, as a member of the health team, we have to respect each other and not look down upon another profession as each profession in the team is important in its own right.’ ‘They [nurses] are there to help us with the patient problem and are very useful because they remind us what we have not done.’ ‘ … it is important to value the judgement of colleagues.’ It was interesting that participants observed that the nurses perceived themselves to be not as valuable as other team members. ‘Other professions [nurses] should stop limiting themselves and stop sitting in the corner, they should stand right next to the doctor.’ • that working as a team creates a feeling of achievement and will improve patient care: ‘We cannot stand alone and do the work, we need other professions to do the work better.’ ‘We need to involve other disciplines more to achieve optimum care for our patients … ’ ‘Working together is wonderful.’

Research Theme three: Skills needed for working as a team Participants realised which skills, other than clinical skills, they need to acquire: Leadership. They reflected on the need to clearly delegate work and direct team members.[9] ‘In the beginning there was no leader … no one took the initiative to start the whole thing.’ ‘I have learned how to take [the] lead [in] an emergency situation, and also how to follow another colleague when he is in charge of an emergency.’ Clear communication. This competency is most commonly emphasised as needed for collaborative practice and teamwork. There was a realisation that the team members need to articulate more clearly.[10] ‘I have to be a good leader and have good communication skills.’ ‘I did not know who should suture the wound, no orders were given.’ ‘We lacked on the communication part.’ Theme four: Effect of being observed by peers Some of the participants who actively participated in the simulation in front of their peers reflected that they felt intimidated and nervous, as they were being watched by their peers. The large number of onlookers, and because everybody was not as exposed to critisism as the participants in the simulation, added to their uneasiness. ‘I think this is a good initiative, but it should be done by small numbers of students so that participation is maximum with no bystanders only the examiner, so that students can confidently participate without psychological inferiority and fear due to the large number of group mates.’ ‘I was nervous because I was being watched.’ Theme five: IPE in the curriculum Participants expressed the need for IPE to become a formal part of their curriculum as they realised the need for better understanding of professional roles. Students also realised the potential of learning from each other: ‘We strongly need to interact with other professions. We should start working together or have tutorials/discussions to improve on our knowledge and skills.’ ‘It should be done on a regular basis.’

Discussion

IPE was generally well received by participants. The outcomes concur with recent studies that report participants’ positive attitudes towards this mode of education, gains in their knowledge (understanding of roles and care content), team skills, leadership, and communication.[1] One key competency of interprofessional collaborative practice for patient-centred care not addressed by participants was negotiation for conflict resolution.[11] Participants noted that the simulation in a controlled environment was a good learning experience, supported by the increase in test scores. However, the significant increase in knowledge, as measured by the MCQ test related to trauma management, can be ascribed not only to learning with members of another profession but also to the repetition of the test and the simulation itself. Participants experienced difficulty in translating the theory they acquired in class into practice and prioritising actions during the simulation. Strategies such as interactive and experiential teaching are well suited for enhancing their practical skills and considered essential to the successful delivery of IPE within student groups with diverse levels of experience.[3] Simulation provides the ideal educational strategy, as it demands practical experience with an interactive element that is authentic and true to the principles of

adult learning.[10] The use of ‘real’ patient scenarios in simulation is therefore highly valued as a vehicle for small-group, mixed professional learning.[12] Interdependence in education also highlights the importance of understanding and appreciating the roles, responsibilities and skills of other healthcare workers.[2] IPE literature reviews describe the outcomes as the development of team-related competencies such as mutual respect, role knowledge and clarification, patient-centred care, and team communication. Interprofessional teams form an integral part of the vision of interdependence in education and highlight the importance of understanding and appreciating the roles, responsibilities and skills of other healthcare workers.[2] It is noteworthy that some participants felt intimidated being observed and preferred less exposure to peers, especially those they did not know. Being watched is intimidating,[13] and discomfort due to peer assessment is reported as having a negative impact on the co-operative, non-judgemental atmosphere of groups.[14] Participants commented on the need for IPE to become a formal part of the curriculum, which concurs with the general satisfaction with these training activities expressed in the literature.[1] A global scan on IPE revealed that, although research evidence shows that IPE should be a mandatory component of every health professional’s education, only 38% reported that this activity was mandatory for all students.[15]

Conclusion

Medical students gained clinical insight during the simulation and became aware of their lack of skills and knowledge, as well as the value of shared learning. Evidence from the literature and perceptions of our students indicate that IPE could be very beneficial to all students if integrated into the formal curriculum, with sufficient time for all students to participate, preferably without being observed and assessed by peers. Our study confirms that IPE at Medunsa is a beneficial mode of education and in future should foster an interest in designing and delivering these structured learning experiences in the various curricula at our institution. IPE events have the potential to expand students’ understanding of the contribution made by other professionals and to give them the opportunity to acquire and practise skills required for effective teamwork. References

1. Abu-Rish E, Kim S, Choe L, et al. Current trends in interprofessional education of health science students; a literature review. J Interprof Care 2012;26(6):444-451. [http://dx.doi.org/10.3109/13561820.2012.715604] 2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/S0140-6736(10)61854-5] 3. Forte A, Fowler P. Participation in interprofessional education: An evaluation of student and staff experiences. J Interprof Care 2009;23(1):55-66. [http://dx.doi.org/10.1080/13561820802551874] 4. Kanter SL. Can we improve interprofessional team-based patient care without calling 911? Acad Med 2012;87(3):253-254. [http://dx.doi.org/10.1097/ACM.0b013e31824aabcd] 5. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional education: BEME Guide No. 9. Med Teach 2007;29(8):735-751. [http://dx.doi.org/10.1080/01421590701682576] 6. Teunissen PW, Scheele F, Scherpbier AJJA, et al. How residents learn: Qualitative evidence for the pivotal role of clinical activities. Med Educ 2007;41(8):763-770. [http://dx.doi.org/10.1111/j.1365-2923.2007.02778.x] 7. Blackstock FC, Jull GA. High fidelity patient simulation in physiotherapy education. Australian Journal of Physiotherapy 2007;53(1):3-5. [http://dx.doi.org/10.1016/S0004-9514(07)70056-9] 8. McNemar’s test. Statistic solutions. http://www.statisticssolutions.com/academic-solutions/resources/directoryof-statistical-analyses/mcnemars-test/ (accessed 10 March 2014). 9. Suter W, Arndt J, Arthur N, Parboossingh J, Taylor E, Deutchlander S. Role understanding and effective communication as core competencies for collaborative practice. J Interprof Care 2009;23(1):41-51. [http://dx.doi. org/10.1080/13561820802338579] 10. Bligh J, Bleakley A. Distributing menus to hungry learners: Can learning by simulation become simulation of learning? Med Teach 2006;28(7):606-613. [http://dx.doi.org/10.1080/01421590601042335] 11. Macdonald MB, Bally JM, Ferguson LM, et al. Knowledge of the professional role of others: A key interprofessional competency. Nurse Educ Pract 2010;10(4):238-242. [http://dx.doi.org/10.1016/j.nepr.2009.11.012] 12. Howden S, Cable S, Harrasi SA, et al. Evaluating a Strategy to Assist Undergraduate Healthcare Students to Gain Insights into the Value of Interprofessional Education Experiences from Recently Qualified Healthcare Professionals (HSAP Repository module: m10246 2011). Edinburgh: The Higher Education Academy, Queen Margaret University, 2011. http://repos.hsap.kcl.ac.uk/content/m10246/1.1/ (accessed 3 December 2012). 13. Practical Doc. Practical observation techniques. http://www.practicaldoc.ca/teaching/practical-prof/ observation-feedback/practical-observation-techniques/ (accessed 1 April 2013). 14. Papinczak T, Young L, Groves M. Peer assessment in problem-based learning: A qualitative study. Advances in Health Sciences Education Theory and Practice 2007;12(2):169-186. [http://dx.doi.org/10.1007/s10459-005-5046-6] 15. Rodger S, Hoffman SJ. Where in the world is interprofessional education? A global environmental scan. J Interprof Care 2010;24(5):479-491.

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Research Are further education opportunities for emergency care technicians needed and do they exist? C Vincent-Lambert,1 PhD; J Bezuidenhout,2 DTech Ed; M Jansen van Vuuren,2 PhD, MMed Fam 1

Department of Emergency Medical Care, University of Johannesburg, South Africa

Division of Health Science Education, University of the Free State, Bloemfontein, South Africa

Corresponding author: C Vincent-Lambert (clambert@uj.ac.za)

Background. A recent review of emergency care education and training in South Africa resulted in the creation of a new 2-year, 240-credit National Qualifications Framework (NQF) level 6 Emergency Care Technician (ECT) qualification. The National Department of Health (NDoH) view ECTs as ‘mid-level workers’ in the emergency care profession. Concurrently, an existing 3-year National Diploma and a 1-year BTech programme were consolidated to form a single 4-year, 480-credit, NQF level 8 professional Bachelor Degree in Emergency Medical Care (B EMC). This study critically analysed and compared the ECT mid-level worker qualification with the professional B EMC degree to design a framework and bridging programme to support articulation between the two qualifications. Methods. The researchers used an expository, retrospective critical analysis of existing documentation followed by a focus group discussion and a Delphi questionnaire. These processes ultimately informed the design of the framework and contents of a bridging programme. Results. Similarities and substantial differences were identified between the ECT and B EMC qualifications in relation to scope, complexity and depth of knowledge. A framework for articulation was designed, which included a bridging programme for ECT graduates wishing to enter the B EMC degree programme. Conclusion. The study predicted a strong sustained demand from ECTs as mid-level workers for further study and associated professional development. It is possible for graduates of the 2-year ECT programme to articulate directly into the third year of the B EMC degree through successful completion of a bridging programme. AJHPE 2014;6(1):6-9. DOI:10.7196/AJHPE.285

Prior to 1980, there were neither professional qualifications nor a professional board for emergency care practitioners in South Africa. Emergency care training was fragmented and varied among provinces. A number of standardised short courses were introduced in 1985. These consisted of a 3-week Basic Ambulance Attendant (BAA), an 8-week Ambulance Emergency Attendant (AEA) and a 4-month Critical Care Assistant (CCA) course.[1-3] The BAA, AEA and CCA short courses were initially offered as a form of in-service training by the provincial Ambulance Training Colleges (ATCs). The primary focus of the short courses was on clinical skills training. As a result, the scope of practice of short-course graduates was designed around rigidly defined medical directives and clinical protocols, leaving clinical decision making and governance to medical doctors. A shortage of qualified emergency medical doctors led to inadequate clinical governance being provided to emergency care workers who were increasingly being required to function as independent clinicians. To support the required levels of independent clinical decision making and practice, the need arose for formal higher education (HE) qualifications in pre-hospital emergency care, which would be recognised, regulated and registered by the Health Professions Council of South Africa (HPCSA).[4,5] The first of these qualifications was a 3-year National Diploma in Ambulance and Emergency Technology (N Dip AET), introduced in 1987. From 2003 onwards, a Bachelor of Technology Degree in Emergency

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Medical Care could also be obtained by completing an additional two years of part-time study, after obtaining the undergraduate 3-year N Dip AET qualification.[4,5] Apart from the CCA course, which was extended to include an additional five months of clinical roadwork, the short courses remained relatively unchanged since their inception. In contrast, the HE programmes continued to evolve via a number of extensive re-curriculation efforts. Since January 2005, Master’s and Doctoral programmes have also been available to Bachelor of Technology (B Tech) graduates.[6,7] With time, serious problems within short-course education and training structures began to emerge. The HPCSA became inundated with requests from multiple role players, all wishing to establish small colleges to offer the emergency care short courses.[8,9] As many as 60 providers were accredited by 2005 and the HPCSA began to receive numerous complaints regarding the quality of short-course training.[9] Within a relatively short period the number of short course graduates, specifically from the basic ambulance courses, far exceeded the number of available posts. Another challenge emerged as articulation between the short courses and the HE qualifications became increasingly difficult owing to the everwidening knowledge gap. Further frustrating the efforts of educators was the fact that the academic architecture of the short courses could not be aligned with the new National Qualifications Framework (NQF). They were also not compliant with South African Qualifications Authority (SAQA) requirements for registration of qualifications on the NQF. SAQA is the

Research ‘Body responsible for overseeing the development and implementation of the National Qualifications Framework, established in terms of the SAQA Act No. 58 of 1995’.[10] The NQF is a ‘Framework on which standards and qualifications, agreed to by education and training stakeholders throughout the country, are registered’.[10] It became clear that a new approach was needed that could address important issues of lifelong learning, academic progression, career-pathing and general professional development within the emergency care industry. The challenge lay in designing a SAQA and NQF-compliant education and training structure, which would meet the needs of the National Department of Health (NDoH) and the emergency care industry. Together with input from role players, including the NDoH, the HPCSA reviewed the learning outcomes of the existing short courses. This led to the design of an evidence-based, formal, 2-year, 240-credit NQF level 6 Emergency Medical Care Technician (ECT) qualification. The NDoH views ECTs as ‘mid-level workers’ within the emergency care profession. Although new in South Africa, mid-level health worker programmes are already in place in a number of other countries.[11] Locally, similar to the ECT, other mid-level worker programmes look set to be introduced in many other registered professions. These include medicine, radiography, and environmental health.[12] The first intake of ECT students took place in 2007 at provincial ATCs and at one university of technology.[13] At the HE level, the 3-year National Diploma and 1-year B Tech programme were merged to form a single, 4-year, 480-credit, NQF level 8 B EMC degree. This degree allows for direct articulation with relevant Master’s and Doctoral programmes.

Objective

The main aim of the study was to design a framework and pathway to facilitate and support articulation between the ECT mid-level worker qualification and the professional B EMC degree.

Methods

The researchers used an exploratory, sequential mixed-method design, which is characterised by a qualitative phase of research followed by a quantitative phase. This design is useful to explore a topic, using qualitative data before attempting to measure it quantitatively.[14] The qualitative phase of the study involved document analysis, a literature review and a focus group interview. The quantitative aspect of the study took place in the form of a Delphi survey. With this design, the researcher critically compared the structure, learning outcomes and methods of delivery of the ECT and B EMC programmes. It also included identification of potential obstacles and challenges relating to articulation between the two qualifications. The subsequent findings were used to inform and refine the design of the framework for articulation and associated bridging programme.[14]

Literature review and document analysis

The starting point in the research process involved a review of the literature around paramedic education and training, followed by an in-depth analysis of existing coursework and curricula documents relating to the ECT and B EMC programmes. This literature review and document analysis provided the researchers with a more thorough understanding of the similarities and differences between the ECT and B EMC qualifications.

Critical comparison of these two qualifications was further assisted by the identification and use of predetermined criteria similar to those used by SAQA for the recording and registering of academic qualifications. Selection of the SAQA criteria was both logical and important as both qualifications had previously been lodged with SAQA on similar templates.

Focus group interview

Seven purposively selected participants took part in a focus group interview. They comprised representatives of the Professional Board for Emergency Care, the NDoH (HR and Training), principals of provincial Health Training Structures (Gauteng and Limpopo) and academics from HE institutions offering the B EMC degree. The focus group interview focused on four key areas: • the need for articulation between the ECT and B EMC qualifications • how well the ECT programme prepares graduates for further study in the NQF • the academic structure of the ECT and B EMC programmes • the need for a bridging programme, and potential problems associated with the bridging process/programme. The focus group interview was recorded and a verbatim transcript produced. Content analysis was used and data were placed into common themes and categories.

The Delphi technique

In the absence of literature addressing articulation between the relatively new ECT and B EMC programmes, other sources of information and data had to be explored. Following the literature review, document analysis and focus group interview a Delphi questionnaire was used to gather additional quantitative data on the content of and articulation between the two programmes. The Delphi questionnaire was e-mailed to expert panel members purposely selected according to predetermined criteria. They completed the questionnaire electronically and e-mailed it back to the researcher after each of three rounds. The researcher analysed the responses from each of the panel members. The format of the Delphi and statements remained consistent between the three rounds. For the purpose of this study, consensus was defined as having been achieved where at least 9/11 or 82% of the participants’ responses fell in the same range, i.e. 1 = essential/ agree, 2 = useful/undecided, or 3 = unnecessary/disagree, as indicated per statement.[13] The Delphi questionnaire consisted of seven sections and 1 051 statements. The first three sections focused on eliciting views and opinions that could serve as potential solutions to the obstacles and challenges that educational managers are likely to face in articulating the mid-level worker ECT graduate into the B EMC programme. The remaining four sections focused on identifying potential learning outcomes for a bridging programme. The following sections of the Delphi survey were selected to inform the framework for articulation:[13] Section A. This section contained eight statements focusing on exploring participants’ views regarding the demand, desire and/or motivation for articulation between the ECT and B EMC and possible factors affecting such a demand. Analysis of the statements and responses in this section confirmed that there is a real and sustained demand for articulation between the ECT and B EMC programmes.

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Research

Analysis of the data from the above research processes led to a number of important results and findings described below. These in turn were used to inform the design of the framework for articulation. • The primary function of the ECT and B EMC programmes is to produce mid-level workers and professional practitioners, respectively. Therefore, the level of depth, complexity and scope of the two programmes differ significantly. There are however topics common to both programmes, i.e. a fundamental knowledge of anatomy, emergency medical care, professional practice and introductory rescue. • While the abovementioned similarities may assist in gaining the academic credits required for advanced placement within the B EMC degree, differences in the scope and level of depth achieved in a number of areas preclude ECT graduates from simply entering directly into the third year of the B EMC degree. Areas identified as requiring deeper understanding included physiology, diagnostics, general pathology and health sciences (chemistry and physics). • The didactic methodologies of the provincial colleges offering the ECT programme were also seen as very different from those at universities offering the B EMC programmes. • The NDoH has expressed a strong desire for ECT graduates to spend some time working as mid-level workers before continuing their studies. Certain academics are in favour of this, arguing that a period of work will consolidate knowledge and improve clinical skills before entering the degree programme. Others argue that a break in studies is not always desirable due to potential knowledge decline. • There is a desire to limit the time away from work when ECT graduates embark on further study. Therefore it is suggested that the bridging programme be offered as a limited-contact programme.[13] A proposed framework for articulation is presented in Fig. 1, followed by a brief discussion of the central key components.

Discussion

The main factors driving the demand for articulation and further study appear to be the ECTs’ desire for increased recognition and status within the profession, enhancing their clinical scope of practice and enjoying associated benefits such as promotion and improved salaries.

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Year 1 Year 2

Two-year ECT programme

Graduate as an ECT

Application for credits/RPL for 1st year subjects

Year 1

Application for credit/RPL for 2nd year

Year 2

1st year of clinical work Apply for bridging programme 2nd year of clinical work

Year 3

Basic sciences Physiology Diagnostics Pathology Clinical learning portfolio

Four-year BHS EMC programme

Results

The process of articulation is not possible without completing the ECT qualification. While certain members of the focus group panel did not feel that a period of work post qualification was necessary for ECT graduates wishing to continue into the B EMC degree, the majority consensus was that a period of clinical practice as an ECT was indeed desirable.[12] The authors agree that ECT graduates should make a contribution to the workforce as mid-level workers before moving into the degree programme so that the objective of the ECT programme is not defeated, i.e. to produce additional numbers of qualified staff for local emergency services. Furthermore, it is unrealistic to assume that every ECT graduate will move on and obtain a professional degree. The framework proposes that at the end of their first year of practice, ECTs who wish to study further apply to enter a structured bridging programme (during their second year of clinical practice). The aim of this programme would be to prepare them for advanced placement in year three of the degree programme. Applicants may also submit a portfolio documenting their clinical work and prior learning as well as continued professional development activities post qualification as an ECT. The portfolio may be further developed and expanded while completing a bridging programme. Vincent-Lambert[13] showed that, although a number of similarities do exist between the 2-year ECT programme and the first two years of the degree programmes, there remain a number of shortfalls in terms of the academic level and depth of knowledge in the following key areas: physics, chemistry, physiology, general pathology, diagnostics and selected areas of clinical exposure. The framework therefore includes a bridging programme with modules that focus on addressing the abovementioned knowledge gaps identified in the study. These need to be covered at the same academic level as those offered during years one and two of the degree programme. In summary, the main aim of the bridging programme would be to ensure that the foundation and core knowledge of an ECT graduate, having

Bridging programme

Section B. This section contained 19 statements focusing on the extent to which the ECT programme prepares the graduate for further academic study within the NQF and, more specifically, to articulate into the B EMC degree. Analysis of the statements and responses in this section of the questionnaire confirmed that there are a number of differences and similarities between the learning outcomes of the 2-year ECT programme and those covered during the first two years of the B EMC degree. These differences and similarities become important when attempting to facilitate articulation between the two qualifications.[13] Section C. This section contained 10 statements aimed at eliciting the participants’ views around the possible format and structure of a framework and bridging programme that may support academic articulation between the ECT mid-level worker qualification and the B EMC degree. Analysis of the responses showed strong similarities and agreements regarding the themes and trends that emerged from the focus group discussion.

Year 4

Graduate with degree

Fig. 1. Framework for articulation between the Emergency Care Technician certificate and the professional degree in emergency medical care[13] (RPL = recognition of prior learning; BHS = Bachelor of Health Sciences; ECT = emergency care technician; EMC = emergency medical care).

Research successfully completed the bridging programme, would be exactly the same as that of a B EMC student at the end of their second year of study. This will allow ECT diplomates who have completed the bridging programme to join the Bachelor degree students who are entering their third year of the B EMC programme. It is acknowledged that B EMC degree programmes differ somewhat in terms of academic architecture, depth and content. Therefore, each institution will need to compare the content of the suggested bridging programme with that of their physiology, diagnostics, general pathology, physics and chemistry modules. Similarly, the awarding of academic credits and/or recognition of prior learning will be guided by the policies and procedures of the respective higher education institutions.

Conclusion

There remains a shortage of tertiary-qualified emergency care workers in South Africa, especially practitioners with advanced life-support skills. The majority of current emergency medical service staff lack formal qualifications and the new mid-level worker ECT programme provides an exciting opportunity for entry into the NQF. Mid-level worker programmes look set to remain and even expand with additional training providers being accredited each year in a number of professions. The subsequent demand of growing numbers of mid-level workers for further career development and learning opportunities may be partially addressed by creating opportunities for entry into Bachelor degree programmes. This study predicts that there will be a sustained demand by ECT graduates in the emergency care profession to further their studies and obtain the B EMC degree. Articulation between the ECT programme and the third year of the B MEC degree may indeed be possible through completion of a bridging

programme. The first pilot of the bridging programme was conducted at the University of Johannesburg with 10 ECT graduates from the North West Province during 2013. Funding. This study was funded by the Division Health Sciences Education, University of the Free State, and the Faculty of Health Sciences, University of Johannesburg. Acknowledgements. We appreciate the input of Professor Vanessa Burch, University of Cape Town, with regard to editing and insight in writing this article. References 1. Health Professions Council of South Africa. Curriculum for the Critical Care Assistant Course. Doc. 5. Part 1. Pretoria: HPCSA, 1999. 2. Health Professions Council of South Africa. Curriculum for the Ambulance Emergency Assistant Course. Doc. 4. Part 1. Pretoria: HPCSA, 1999. 3. Health Professions Council of South Africa. Curriculum for the Basic Ambulance Assistant Course. Doc. 2. Part 1. Pretoria: HPCSA, 1999. 4. Health Professions Council of South Africa. EC News: Newsletter of the Professional Board for Emergency Care. Pretoria: HPCSA, 2006. 5. South African Qualifications Authority. Bachelor of Technology Degree. Emergency Medical Care. Pretoria: SAQA, 2009. http://allqs.saqa.org.za/showQualification.php?id=71789 (accessed 15 March 2010). 6. South African Qualifications Authority. Master of Emergency Medicine. Pretoria: SAQA, 2013. http://allqs.saqa. org.za/showQualification.php?id=88323 (accessed 30 April 2013). 7. South African Qualifications Authority. Doctor of Philosophy: Emergency Medicine. Pretoria: SAQA, 2013. http://allqs.saqa.org.za/showQualification.php?id=80926 (accessed 30 April 2013). 8. Naidoo R. Presentation at the Second Meeting of the Professional Board for Emergency Care, Idle Winds, Hartebeespoort, 25 February 2011. 9. Health Professions Council of South Africa. EC News: Newsletter of the Professional Board for Emergency Care. Pretoria: HPCSA, 2009. 10. South African Qualifications Authority. The National Qualification Brochure. http://www.saqa.org.za/docs/ brochures/nqf-brochure.html (accessed 27 March 2013). 11. Dovlo D. Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review, 2004. http://www.human-resources-health.com/content/2/1/7 (accessed 20 June 2010). 12. University of Witwatersrand. Clinical Associates, Bachelor of Clinical Medical Practice programme, 2013. Http:// www.wits.ac.za/academic/health/entities/ruralhealth/10098/clinical_associates_bcmp_degree_programme.html (accessed 27 March 2013). 13. Vincent-Lambert C. A framework for articulation between the Emergency Care Technician Certificate and the Emergency Medical Care Professional Degree. Doctoral thesis. University of the Free State, Bloemfontein, 2012. 14. Ivankova NV, Creswell JW, Plano Clark VL. Foundations and approaches to mixed methods research. In: Maree K, ed. First Steps in Research. Pretoria: Van Schaik Publishers, 1995.

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Research How we see ‘Y’: South African health sciences students’ and lecturers’ perceptions of Generation Y students L J van der Merwe,1 MB ChB, MMedSc, PhD; G J van Zyl,2 MB ChB, MMed, PhD; M M Nel,3 PhD; G Joubert,4 BA, MSc 1

Department of Basic Medical Sciences, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Division Health Professions Education, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Corresponding author: L J van der Merwe (merwelj@ufs.ac.za)

Background. Health sciences education in the 21st century must recognise the changing profile of students, which includes an understanding of the characteristics of Generation Y students (born between 1981 and 2000) as future healthcare professionals. Objective. To examine the perceptions of students and lecturers regarding Generation Y students in health sciences that might impact on teaching and learning in a South African setting. Methods. A quantitative research approach was used to determine undergraduate students’ and lecturers’ perceptions of Generation Y students in the Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa. Anonymous questionnaires were used to obtain information. Results. The study population included students (n=616) and lecturers (n=71). Despite some shared perceptions about generational characteristics, students and lecturers differed significantly on many issues. Unlike lecturers, students perceived themselves as being ambitious (not arrogant) and possessing superior cognitive skills. Despite desiring a vibrant and stimulating learning environment, students wanted face-to-face contact with lecturers. Poor intergenerational communication also emerged as a pertinent issue. Conclusion. Identification of intergenerational issues that may impact on teaching and learning may contribute to developing novel educational approaches acceptable to both lecturers and students. AJHPE 2014;6(1):10-16. DOI:10.7196/AJHPE.307

Innovative educational approaches must meet 21st century healthcare and education requirements. Professional educators and students (as future professionals) are healthcare stakeholders who must take responsibility for meeting the challenges of improving healthcare for patients and populations by attending to the knowledge, skills and attitudes of future healthcare professionals.[1] Current undergraduate students, or Generation Y (also referred to as Millennials or the Net Generation), born between 1981 and 2000, have a distinct profile and characteristics as a result of the era during which they were born.[2] They are said to be confident and ambitious, preferring specific learning styles, including active experiential learning and multitasking, and communication technology for information access and interpersonal relationships.[3,4] Their world has been shaped by the informationcommunication technology (ICT) revolution, and global social, political and economic changes that have an impact on their attitudes and behaviours.[5] This discourse has led to a trend in health sciences education, i.e. incorporating technology to address the challenges found in teaching and learning.[6] An awareness of Generation Y’s characteristics is essential when addressing current issues and planning future strategies in academic medicine.[7] However, caution should be exercised when attempting to separate myth from reality regarding the core behaviours and attitudes of Generation Y students. An understanding of how different generations view each other, and exploring the impact on teaching and learning, should precede any intended changes to education.[8] Limited empirical data regarding Generation Y characteristics beyond the hype portrayed in the popular media are available, and a more conservative view regarding the sweeping claims about ‘digital natives’ is advisable.[8,9]

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We aimed to explore the characteristics of Generation Y health sciences students that impact on the teaching-learning environment. Information was obtained on the shared and contrasting perceptions of students and lecturers, typical characteristics of Generation Y students, and issues of significance that may impact on health sciences education and then scrutinising these in light of current pedagogical theory. For this purpose, a questionnaire survey was designed based on the literature regarding Generation Y, including aspects pertinent to health sciences education.[2,3,6,10] The study hypothesised that by gaining a better understanding of Generation Y students, uncovering misunderstandings or conflicting perceptions between students and lecturers and discovering students’ unique needs, the strategies for health sciences education in the 21st century may be improved. Four key elements pertinent to educating Generation Y students in health sciences were identified as relevant to this study, including the educational environment, Generation Y students’ personal attributes, their learning styles and needs, and issues of professional communication between students, lecturers, patients, colleagues, families and peers. This approach aligns with the pedagogical principles for effective practice in undergraduate education (Table 1).[11,12]

Methods

This cross-sectional study was performed using a quantitative research design.

Participants

All students in their second or final year of undergraduate study in the Schools of Medicine, Allied Health Professions and Nursing in the Faculty

Research Table 1. Key elements pertinent to the educational approach for Generation Y students aligned with theoretical frameworks informing undergraduate education[11,12] Four key elements

Seven good practices

Twelve attributes of quality

A. Educational environment

1. Give prompt feedback 2. Encourage student-faculty contact

i. Assessment and prompt feedback ii. Out-of-class contact with faculty iii. Emphasis on early years of study

B. Personal attributes

3. Encourage co-operation among students 4. Emphasise time on task

iv. Collaboration v. Adequate time on task vi. Synthesis of experiences

C. Learning styles and needs

5. Encourage active learning

vii. Active learning viii. Integration of education and experiences ix. Ongoing practice of learned skills

D. Professional communication

6. Communicate high expectations 7. Respect diverse talents and ways of learning

x. High expectations xi. Respect for diverse talents and learning styles xii. Coherence in learning

The questionnaires for students and lecturers were similar, with the exception of the sections on demographic and personal information.

Table 2. Demographic data of the participants Undergraduate students School in the Faculty of Health Sciences Medicine

Allied Health

Nursing

Pilot study

Lecturers

Gender, n

322

Male

158

49.1

17.7

14.7

35.2

Female

164

50.9

186

82.3

85.3

64.8

A pilot study included 10 third-year students and two lecturers from the Schools of Medicine, Allied Health Professions and Nursing, respectively. No changes to the questionnaires were required after the pilot study.

Data analysis

Variable

Total

Total % 226

Total %

Total

Ethnicity, n

320

Black

28.4

4.0

47.1

2.9

White

202

63.1

211

93.4

50.0

97.1

Other

8.5

2.6

2.9

Home language, n

321

English

13.1

13.8

4.4

16.9

Afrikaans

188

5 867

183

81.7

48.5

80.3

28.3

4.5

328

47.1

2.8

Black African indigenous language 91

226

(2010 figures from the Directorate Institutional Research and Planning, UFS). Lecturers were also invited to voluntarily complete an anonymous questionnaire online or in printed format.

Statistical analysis of quantitative data was done by a biostatistician using the SAS programme[15] to calculate frequencies and percentages for the categorical variables and means, and standard deviations or percentiles as appropriate for the numerical variables. Associations between categorical variables were determined using contingency tables with 95% confidence intervals (CIs) for the differences in percentages and chi-square tests or Fisher’s exact tests where the expected numbers in the cells of tables were small. A p-value <0.05 was considered to be statistically significant.

Questionnaire survey

Ethical requirements

224

of Health Sciences, University of the Free State (UFS), Bloemfontein, South Africa, were invited to participate in the study. Students were requested to voluntarily complete an anonymous questionnaire during academic contact sessions in March 2010. Second-year students were included in the sample because of the assumption that they would have adapted to their course and university environment by the end of their first year. The opinions of older, more mature students with some exposure to the working environment of their respective occupations were obtained. These included fourthand fifth-year students in the five-year MB ChB course and fourth-year students in the other fouryear courses, with the exception of third-year students in the three-year BSc Radiation Science course. The target population (N=668) included second-year (n=277) and senior (n=391) students

The questionnaires, based on recommended guidelines,[13] were available in Afrikaans and English, the languages of instruction at UFS, where a parallel language policy is followed.[14] Undergraduate students’ and lecturers’ perceptions regarding statements about Generation Y students were determined employing a modified 4-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree). For reporting purposes, responses 1 and 2 were grouped together to indicate disagreement, and responses 3 and 4 to indicate agreement with statements.

Ethics approval was obtained from the Ethics Committee of the Faculty of Health Sciences, UFS (Ethics approval No. ETOVS 205/09).

Results

Demographic information

Table 2 shows the demographic details of the students and lecturers who participated in the study. A total of 616 students completed the survey during March 2010 (response rate 92.2%). Students from the School of Medicine comprised

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Research 52.3% (n=322) of the sample; 36.7% (n=226) were from the School of Allied Health Professions and 11.0% (n=68) were nursing students. The majority of students were white (72.7%; n=448) and Afrikaans speaking (66.1%; n=407). English was the first language of only 12.3% (n=76) of all students. Of the remaining students, 21.4% (n=132) were black African, with an indigenous language as their mother tongue. The remainder of the cohort included Indian (n=5), Asian (n=3), and mixed-ancestry (coloured, n=24) students. Three students did not specify their ethnicity. Seventy-one lecturers participated in the survey – a response rate of 34.5%, which falls within the norm of 35 - 40% described for studies at organisational level.[16] The respondents included 47 (66.2%) lecturers from the School of Medicine, 20 (28.2%) from the School of Allied Health Professions, and four (5.6%) from the School of Nursing. They were mostly female (60.6%), Afrikaans speaking (80.3%) and white (95.7%), of whom 34.3% (n=23) were born between 1944 and 1960 (Baby Boomers), and 64.2% (n=43) between 1961 and 1980 (Generation X). One participant represented Generation Y (born between 1981 and 2000).[10,17]

Summary of significant findings from questionnaire surveys

The results from the questionnaire surveys reflected the perceptions of students and lecturers regarding Generation Y students, and are presented according to the key elements of the educational framework used in this study (Table 1). Educational environment. Students and lecturers agreed that Generation Y students cannot imagine a world without technology, function best in a structured, organised environment and regard a team environment as

optimal for learning. Table 3 summarises statements where significant differences were observed between students and lecturers. Significantly more lecturers than students indicated that Generation Y students prefer empathetic role models (students 71.3%, lecturers 95.5%), need motivational leadership (students 71.5%, lecturers 90.5%), or need guided supervision, preferably by an older mentor (students 56.7%, lecturers 80.9%). Compared with lecturers, less than 50% of students agreed that Generation Y students prefer an anonymous, open online environment (students 28.0%, lecturers 82.1%), or consider the internet to be a way of life rather than just a form of technology (students 47.5%, lecturers 93.9%). Significantly more students agreed that Generation Y students grew up in a structured, organised environment (students 89%, lecturers 29.7%) and are used to obeying rules (students 93.3%, lecturers 29.7%). Students and lecturers agreed that Generation Y students think that lecturers should give each student individual feedback on a regular basis, and that when a lecturer gives negative feedback, they should explain or justify it. Significantly more lecturers indicated that Generation Y students want immediate, personal access to lecturers whenever it suits them (students 46.7%, lecturers 86.8%), and that they prefer positive feedback because negative feedback is destructive (students 54.4%, lecturers 88.2%) (Table 3). Personal attributes. Students and lecturers agreed that Generation Y students are friendly and pleasant, display positive, assertive behaviour, are optimistic about the future, appear confident and have a high self-esteem. Table 4 illustrates statements where significant differences were seen between students and lecturers.

Table 3. Significant differences between perceptions of students and lecturers regarding the educational environment of Generation Y students Students

Lecturers

Respondents

Agree*

Respondents

Agree*

n (%)

p-value (95% CI)

… think the internet is more than technology, it is a way of life

613

291 (47.5)

62 (93.9)

<0.0001 (39.5 - 53.5)

… prefer the anonymous, open online environment

610

171 (28.0)

56 (82.1)

<0.0001 (44.2 - 63.9)

… prefer empathetic role models

606

432 (71.3)

64 (95.5)

<0.0001 (18.1 - 30.4)

… need motivational leadership

593

424 (71.5)

57 (90.5)

0.0012 (10.9 - 27.1)

… need guided supervision, preferably by an older mentor

612

347 (56.7)

55 (80.9)

<0.0001 (14.1 - 34.3)

… grew up in a structured, organised environment

611

544 (89.0)

19 (29.7)

<0.0001 (47.9 - 70.8)

… are used to following rules

610

569 (93.3)

19 (29.7)

<0.0001 (52.2 - 75.0)

…w ant immediate, personal access to lecturers whenever it suits them

612

286 (46.7)

59 (86.8)

<0.0001 (31.1 - 49.0)

… prefer positive feedback because negative feedback is destructive

612

333 (54.4)

60 (88.2)

<0.0001 (25.2 - 42.4)

Statement Generation Y students

CI = confidence interval. * Includes the categories ‘Strongly agree’ and ‘Agree’ on the questionnaire Likert scale.

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Research A significantly higher proportion of lecturers indicated that Generation Y students are self-centred (students 17.6%, lecturers 72.5%), may seem arrogant (students 27.5%, lecturers 59.4%), feel entitled to benefits not yet earned (students 19.6%, lecturers 69.6%), want instant gratification and are not willing to wait for delayed rewards (students 30.0%, lecturers 73.9%) or think that they are entitled to everything they want (students 23.3%, lecturers 72.1%). Significantly more students than lecturers agreed that Generation Y students are ambitious (students 97.4%, lecturers 65.2%), have high expectations of success (students 95.7%, lecturers 77.9%), are motivated to achieve success (students 98.7%, lecturers 85.6%) and aim to achieve a work-life balance (students 98.4%, lecturers 74.6%). Learning styles and needs. Students and lecturers agreed on some of the learning needs of Generation Y students, e.g. that real-life simulations are a valuable way to learn new skills, technology is essential, visual data are better than text data, face-to-face contact with lecturers is essential to understand a subject, e-learning is not better than face-to-face contact, learning should be tailored to individual student needs, group work is a key element of learning and Generation Y students want a constantly changing learning environment. Table 5 illustrates statements where significant differences between the opinions of students and lecturers were seen. Significantly more students agreed that learning is about discovery and exploration (students 90.7%, lecturers 50.8%), experience is a better learning platform than lectures (students 90.5%, lecturers 61.5%), and it is important to incorporate one’s own experiences into the learning experience/process

(students 89.9%, lecturers 70.8%). In addition, a significantly greater proportion of students agreed that Generation Y students can multitask (students 77.4%, lecturers 50%), are active learners (students 87.9%, lecturers 47%), take responsibility for their own learning (students 96.6%, lecturers 49.3%), have good critical thinking skills (students 46.8%, lecturers 27.3%), learning content should be intellectually challenging (students 85.5%, lecturers 57.6%) and students should collaborate on subject content decisions (students 62.7%, lecturers 39.1%). A significantly higher percentage of lecturers agreed that Generation Y students struggle with in-depth learning (students 41.0%, lecturers 89.4%), find it difficult to manage large volumes of written information (students 76.2%, lecturers 93.9%), and find structured supervision frustrating (students 26.8%, lecturers 64.2%). Professional communication. Undergraduate students and lecturers agreed that Generation Y students communicate well with people from diverse cultures. Table 6 illustrates statements with significant differences between students and lecturers. Lecturers and students had contrasting views on the ability of Generation Y students to communicate using technology rather than personal interaction (students 14.0%, lecturers 82.4%), e.g. text messaging rather than face-to-face contact (students 14.9%, lecturers 74.2%). Significantly more lecturers also agreed that Generation Y students find it difficult to communicate with older individuals (students 40.3%, lecturers 70.6%), think that older generations do not understand how to communicate with them (students 42.6%, lecturers 83.8%), and

Table 4. Significant differences in percentage between students and lecturers agreeing with statements regarding Generation Y students’ personal attributes Students

Lecturers

Respondents Agree*

Respondents

Agree*

n (%)

p-value (95% CI)

… are motivated to achieve success

615

607 (98.7)

58 (86.6)

<0.0001 (3.9 - 20.4)

… may seem arrogant

612

168 (27.5)

41 (59.4)

<0.0001 (19.9 - 44.1)

… are self-centred

613

108 (17.6)

50 (72.5)

<0.0001 (43.9 - 65.8)

… feel entitled to benefits not yet earned

613

120 (19.6)

48 (69.6)

<0.0001 (38.7 - 61.3)

… are ambitious

615

597 (97.1)

45 (65.2)

<0.0001 (20.5 - 43.2)

… have high expectations of success

611

585 (95.7)

53 (77.9)

<0.0001 (7.8 - 27.8)

… want instant gratification and are not willing to wait for delayed rewards

613

184 (30.0)

51 (73.9)

<0.0001 (32.9 - 54.9)

… think they are entitled to everything they want

614

143 (23.3)

49 (72.1)

<0.0001 (37.6 - 60.0)

… aim to achieve work-life balance

615

605 (98.4)

50 (74.6)

<0.0001 (13.3 - 34.2)

Statement Generation Y students

CI = confidence interval. * Includes the categories ‘Strongly agree’ and ‘Agree’ on the questionnaire Likert scale.

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Research

Table 5. Significant differences in percentage between students and lecturers agreeing with statements regarding the learning needs of Generation Y students Students

Lecturers

Respondents

Agree*

Respondents

Agree*

n (%)

p-value (95% CI)

… think experience is a better learning platform than lectures

611

553 (90.5)

40 (61.5)

<0.0001 (16.9 - 41.0)

… feel it is important to incorporate own experiences in learning

613

551 (89.9)

46 (70.8)

<0.0001 (7.8 - 30.4)

… think learning is about discovery and exploration

614

557 (90.7)

33 (50.8)

<0.0001 (27.6 - 52.3)

… think traditional lectures are outdated

606

241 (39.8)

35 (54.7)

0.0211 (2.1 - 27.7)

… are active learners

612

538 (87.9)

31 (47.0)

<0.0001 (28.6 - 53.3)

… have good critical thinking skills

613

525 (85.5)

18 (27.3)

<0.0001 (47.1 - 69.3)

… can multitask

611

473 (77.4)

33 (50.0)

<0.0001 (14.9 - 39.9)

… struggle with in-depth learning

603

247 (41.0)

59 (89.4)

<0.0001 (40.0 - 56.8)

… find it difficult to manage large volumes of written information

614

468 (76.2)

62 (93.9)

0.001 (11.1 - 24.4)

… should collaborate on subject content decisions

611

383 (62.7)

25 (39.1)

0.0002 (11.1 - 36.2)

… think that learning content should be intellectually challenging

612

523 (85.5)

38 (57.6)

<0.0001 (15.6 - 40.1)

… learn only what is necessary to pass assessments

613

251 (41.0)

59 (90.8)

<0.0001 (41.8 - 57.9)

… take responsibility for own learning

614

593 (96.6)

33 (49.3)

<0.0001 (35.3 - 59.4)

… find structured supervision frustrating

612

164 (26.8)

43 (64.2)

<0.0001 (25.4 - 49.4)

Statement Generation Y students

CI = confidence interval. * Includes the categories ‘Strongly agree’ and ‘Agree’ on the questionnaire Likert scale.

have a casual approach that may appear to lack professionalism (students 38.1%, lecturers 89.9%). Significantly more students were of the opinion that Generation Y students are good communicators (students 90.0%, lecturers 42.6%), can maintain close, personal relationships (students 94.7%, lecturers 66.7%) and often have superficial, online relationships (students 91.8%, lecturers 79.4%).

Discussion

Current strategies tailored to the educational needs of Generation Y students are mostly based on limited data and vague statements derived from the popular literature.[18] This study provides a comprehensive overview of the personal attributes, preferred learning styles and needs, communication behaviours and educational environment requirements of Generation Y students from the perspective of students and lecturers,

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providing scientifically generated evidence that may inform innovative teaching-learning strategies. We observed major differences in perceptions between students (as members of Generation Y) and lecturers (who belong to previous generations), which may foster conflict and misunderstanding and contribute to the contemporary view that teaching this generational cohort is an important challenge in health sciences education.[19] Students and lecturers shared a positive view that Generation Y students are friendly and pleasant, confident, assertive and optimistic about the future. However, while students viewed themselves as ambitious and motivated for success, lecturers regarded them as self-centred, arrogant, displaying a sense of entitlement and demanding instant gratification. Creating an understanding and awareness of such intergenerational conflicting perceptions should contribute to limiting frustration and fostering good relationships between students and practising clinicians in health sciences

Research

Table 6. Differences between students’ and lecturers’ perceptions regarding aspects of professional communication behaviour of Generation Y students Students

Lecturers

Respondents

Agree*

Respondents

Agree*

n (%)

p-value (95% CI)

… are better at communicating with technology than with personal interaction

613

86 (14.0)

56 (82.4)

<0.0001 (58.9 - 77.8)

… prefer text messaging to face-to-face contact

612

91 (14.9)

49 (74.2)

<0.0001 (48.5 - 70.3)

… find it difficult to communicate with older generations

613

247 (40.3)

48 (70.6)

<0.0001 (18.8 - 41.8)

… think older generations don’t understand how to communicate with them

613

261 (42.6)

57 (83.8)

<0.0001 (31.7 - 50.8)

… have a casual approach that may appear to lack professionalism

614

234 (38.1)

62 (89.9)

<0.0001 (43.7 - 59.8)

… often have superficial online relationships

612

562 (91.8)

50 (79.4)

=0.0012 (2.2 - 22.7)

… can maintain close personal relationships

607

575 (94.7)

44 (66.7)

<0.0001 (16.6 - 39.6)

… are good communicators (verbal/non-verbal)

611

550 (90.0)

29 (42.6)

<0.0001 (35.4 - 59.4)

Statement Generation Y students

CI = confidence interval. *Includes the categories ‘Strongly agree’ and ‘Agree’ on the questionnaire Likert scale.

education. The importance of constructively managing generational diversity in academic medicine has been highlighted previously.[20-23] While our results show that students and lecturers agreed that an organised educational environment incorporating teamwork and individual positive feedback is optimal for learning, significantly more students thought that Generation Y students are accustomed to structure and obeying of rules (Table 3). Significantly fewer students believed that Generation Y students need supervisory mentoring by empathetic role models or prefer the anonymity of technology. Therefore, the current literature advocating extensive use of technology in teaching and learning, based on the assumption that Generation Y students prefer such an approach, may be somewhat misleading.[5,24,25] Our findings support those advocating a more conservative view that innovative technology may not address all the challenges faced in higher education today.[8,26] In this study, students and lecturers agreed that vibrant and fitting learning environments incorporating visual stimulation, simulation and technology are ideal. However, the importance of face-to-face contact with lecturers was valued and should not be disregarded in favour of the predominant use of e-learning strategies. A learning environment appropriate for Generation Y students should therefore strike a balance between nurturing students’ cognitive skills through personal interaction with lecturers (as mentors and facilitators of learning), relevant use of innovative technology and practical experiential learning activities. Students perceived themselves as responsible, active learners, with the ability to multitask – a view not shared by lecturers. Significantly more lecturers thought that students struggle with in-depth learning and handling vast amounts of information, and become frustrated by structured supervision. On the other hand, students emphasised the value of experiential learning that is intellectually challenging and allows

for collaborative input. These contrasting perceptions confirm students’ confidence in their higher-order thinking skills, and emphasise the need for employing a student-centred approach in health sciences education. Adult learning principles, embodied by self-directed learning and active engagement, include creating an environment characterised by freedom of expression and mutual helpfulness, encouraging students’ commitment and dynamic contribution to learning by incorporating their prior knowledge and experience and providing opportunities to practise concepts and skills.[27] Students and lecturers concurred that Generation Y students communicate well with people of diverse cultures. However, significantly more students thought that they were good communicators capable of maintaining healthy interpersonal relationships, while lecturers perceived them to be more adept at communicating by means of technology, and that intergenerational miscommunication and students’ seemingly casual and unprofessional approach hampered their professional communication. The contrast between students who regard themselves as good communicators (in spite of the detrimental effects of technology on their interpersonal relationships) and lecturers who think Generation Y students have limited communication skills, may contribute to challenges arising in the teaching and learning environment. In this study, students matched the typical view of Generation Y as a wired and connected cohort whose face-to-face communication abilities have deteriorated owing to information-communication technology applications in their daily life. Therefore, lecturers should take note of students’ need for guidance and role-modelling in developing communication skills. The value of effective communication in health sciences education cannot be overestimated, as future healthcare professionals must be equipped to effectively interact with patients, colleagues, families and community. The importance of developing and updating clinical communication skills training

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Research is well documented.[28] However, Generation Y students may be prejudiced against training in intergenerational and interpersonal communication skills due to their perceived superior communication proficiency. A limitation of the study is the self-reported data and that students may have felt a compulsion to participate, as the questionnaires were administered during an academic contact session. The anonymous and voluntary nature of their participation was explicitly mentioned, both in the prior briefing and the questionnaire, to eliminate such bias. Secondly, the study may not represent students in other health sciences faculties in South Africa. While a relatively large cohort of students (n=616) and lecturers (n=71) were included in the study, the number of participants could be expanded to include data from other health sciences faculties. The small number of lecturers compared with the number of students has an impact on the significance of differences between the groups. Finally, qualitative exploration of the quantitative findings reported in this publication may yield greater in-depth insight, triangulate the findings (increase validity) and contextualise the knowledge gained.

Conclusion

When considering the design and development of an educational framework, it is imperative that the teaching and learning environment of the 21st century and the needs of Generation Y students are taken into account. This includes identifying areas of misunderstanding between students and lecturers that lead to conflict and impaired relationships. Key focus areas include personal attributes, learning styles and needs, communication skills, and the appropriate educational environment for this generational cohort. This study provided comprehensive data revealing shared perceptions and distinct differences between Generation Y students and lecturers that indicate possible misperceptions or potential unrecognised needs that should be examined further to contribute to progress in health sciences education. Acknowledgements. The authors would like to acknowledge the undergraduate students and academic staff members who participated in the study; Dr Daleen Struwig, medical writer, for technical and editorial assistance with preparation of the manuscript; and Professor Vanessa Burch, Chair of Clinical Medicine, University of Cape Town, for conceptual and editorial advice in planning and preparing the manuscript.

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Declaration of interest. Partial funding for this study was obtained from a postgraduate bursary from the Research Committee, School of Medicine, Faculty of Health Sciences, UFS. References 1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/S0140-6736(10)61854-5] 2. Howe N, Strauss W. Millennials Rising: The Next Great Generation. New York: Vintage e-books, 2000. 3. Earle V, Myrick F. Nursing pedagogy and the intergenerational discourse. J Nurs Educ 2009;48(11):624-630. [http://dx.doi.org/10.3928/01484834-20090716-08] 4. Boateng BA. Should generational characteristics be considered in instructional methods? The instructional preferences of Millennials and its implications for medical education. Internet J Med Educ 2011;2(1):1-12. [http://dx.doi.org/10.5580/26e7] 5. Oblinger D. Boomers, Gen X-ers & Millennials: Understanding the new students. Educause 2003; July/ August:37-47. http://net.educause.edu/ir/library/pdf/erm0342.pdf (accessed 9 July 2013). 6. Sandars J, Morrison C. What is the Net Generation? The challenge for future medical education. Med Teach 2007;29(2-3):85-88. [http://dx.doi.org/10.1080/01421590601176380] 7. Pleotis-Howell L, Joad JP, Callahan E, Servis G, Bonham A. Generational forecasting in academic medicine: A unique method of planning for success in the next two decades. Acad Med 2009;84(8):985-993. [http://dx.doi. org/10.1097/ACM.0b013e3181acf408] 8. Bennett S, Maton K, Kervin L. The ‘digital natives’ debate: A critical review of the evidence. Br J Educ Technol 2008;39(5):775-786. [http://dx.doi.org/10.1111/j.1467-8535.2007.00793.x] 9. Kennedy G, Gray K, Tse J. ‘Net Generation’ medical students: Technological experiences of pre-clinical and clinical students. Med Teach 2008;30(1):10-16. [http://dx.doi.org/10.1080/01421590701798737] 10. Mangold K. Educating a new generation: Teaching baby boomer faculty about millennial students. Nurse Educ 2007;32(1):21-23. [http://dx.doi.org/10.1097/00006223-200701000-00007] 11. Chickering AW, Gamson ZF. Seven principles for good practice in undergraduate education. AAHE Bull 1987;39:3-7. 12. Chickering AW, Gamson ZF. Development and adaptations of the seven principles for good practice in undergraduate education. New Direct Teach Learn 1999;80:75-81. [http://dx.doi.org/10.1002/tl.8006] 13. Eiselen R, Uys T, Potgieter N. Analysing survey data using SPSS13: A Workbook. Johannesburg: University of Johannesburg, 2005. http://www.uj.ac.za/EN/Research/Statkon/Documents/Statkon%20Questionaire!20DEsign.pdf (accessed 14 December 2010). 14. University of the Free State Language Policy, 2003. http://www.ufs.ac.za/dl/userfiles/Documents/00000/335_eng. pdf (accessed 26 August 2011). 15. SAS Institute Inc. SAS/STAT® 9.1 User’s Guide. Cary, NC: SAS Institute Inc., 2004. 16. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Human Relations 2008;61(8):1139-1160. [http://dx.doi.org/10.1177/0018726708094863] 17. Clausing SL, Kurtz DL, Prendeville J, Walt JL. Generational diversity – the Nexters. AORN J 2003;78(3):373-379. [http://dx.doi.org/10.1016/S0001-2092(06)60749-7] 18. Bullen M, Morgan T, Qayyum A. Digital learners in higher education: Generation is not the issue. Can J Learn Technol 2011;37(1):1-24. 19. Seggie JL. A captivating ‘alchemy’– educating doctors for South Africa: The story of MBChB curriculum modernization. Transactions: Journal of the Colleges of Medicine of South Africa 2010;54(1):41-45. http://www. collegemedsa.ac.za/view_document_list.aspx?Keyword=Transactions (accessed 9 July 2013). 20. Howell LP, Servis G, Bonham A. Multigenerational challenges in academic medicine: UCDavis’s responses. Acad Med 2005;80(6):527-532. [http://dx.doi.org/10.1097/00001888-200506000-00003] 21. Lower J. Brace yourself. Here comes Generation Y. Crit Care Nurse 2008;28(5):80-84. 22. Moreno-Walton L, Brunett P, Akhtar S, DeBlieux PM. Teaching across the generation gap: A consensus from the Council of Emergency Medicine Residency Directors 2009 academic assembly. Acad Emerg Med 2009;16(Suppl 2):S19-S24. [http://dx.doi.org/10.1111/j.1553-2712.2009.00601.x] 23. Mohr NM, Moreno-Walton L, Mills AM, Brunett PH, Promes SB. Generational influences in academic emergency medicine: Teaching and learning, mentoring, and technology (Part I). Acad Emerg Med 2011;18(2):190-199. [http://dx.doi.org/10.1111/j.1553-2712.2010.00985.x] 24. Frand JL. The information-age mindset. Changes in students and implications for higher education. Educause 2000; September/October:15-24. http://net.educause.edu/ir/library/pdf/ERM0051.pdf (accessed 9 July 2013). 25. Salaway G, Caruso JB. The ECAR study of undergraduate students and information technology, 2008. http://net. educause.edu/ir/library/pdf/ers0808/rs/ers0808w.pdf (accessed 9 July 2013). 26. Dohn NB. Web 2.0: Inherent tensions and evident challenges for education. Int J Comp Supp Collab Learn 2009;4(3):343-363. [http://dx.doi.org/10.1007/s11412-009-9066-8] 27. Shreeve MW. Beyond the didactic classroom: Educational models to encourage active student involvement in learning. J Chiropract Educ 2008;22(1):23-28. [http://dx.doi.org/10.7899/1042-5055-22.1.23] 28. Brown J. Clinical communication education in the United Kingdom: Some fresh insights. Acad Med 2012;87(8):1101-1104. [http://dx.doi.org/10.1097/ACM.0b013e31825ccbb4]

Research Do physiotherapy students perceive that they are adequately prepared to enter clinical practice? An empirical study H Talberg, BSc (Physio), MPhil (HES); D Scott, BSc (Physio) Department of Health and Rehabilitation Sciences, Division of Physiotherapy, University of Cape Town, South Africa Corresponding author: D Scott (des.scott@uct.ac.za)

Objective. To determine the perceived level of preparedness for clinical practice of third-year physiotherapy students. Design. A prospective, descriptive study, using questionnaires to determine subjective perceptions and clinical test marks for objective measures of performance, was undertaken. Two different cohorts were recruited of third-year students entering clinical practice for the first time. Method. A 17-item questionnaire relating to areas of competence was developed. Results of questionnaire scores and test scores from the 2 cohorts were amalgamated and analysed. Participants were grouped according to their clinical placement. The internal consistency of the questionnaire was tested using Cronbach’s alpha. As this was high at 0.847, the individual scores were added together and the mean score calculated. Analysis of variance (ANOVA) was used to establish if there was a significant difference in scores across different areas of competency and on test marks, across the different clinical settings. Main outcomes measure. Means and 95% confidence intervals of the mean scores of each component of competence indicated a significant difference between the scores (p<0.001). One-way ANOVA and post hoc analysis revealed that the students perceived themselves as better prepared in affect (generic skills) than for intervention and overall preparedness ((F(4, 264)=4.8601, p<0.001). There were no significant differences between the competency mean scores (F(4,53)=0.804, p=0.528), or in the mean test scores, across the placements (F(4, 77)=0.438, p=0.781). Results. Most of the students perceived their level of preparedness as relatively high across all areas of competence, regardless of placement. Students also achieved satisfactory (>60%) test scores, indicating realistic estimations of their ability. Conclusion. The sense of readiness confirms the alignment of the classroom curriculum and clinical expectations, which has largely come about through the positioning of permanent clinical educators as essential links between the classroom and the clinical setting. AJHPE 2014;6(1):17-22. DOI:10.7196/AJHPE.219

Practice within the clinical arena is recognised as the best means of socialising students into the physiotherapy profession[1-5] and is known to make up an integral part of the undergraduate training of all health professionals.[6] Clinical training facilitates the transference of classroomtaught skills and knowledge into practice. In addition, it provides students with the opportunity to learn the behaviours and attitudes necessary for successful professional practice, and to develop negotiation, assertive, organisational and administrative skills while becoming aware of social contexts and resources, in order to be socially responsible.[6] Of concern is how the knowledge acquired by students in the classroom is transferred to, and applied within, clinical placements.[4,7] In a situation where clinical educators work within the clinical arena and academics cover theoretical and practical content but spend less time supervising students in clinics, the expectations of clinicians and academics may differ widely, which may result in a disparity between the taught curriculum and the needs of the clinical placements, affecting the preparedness of students for competent clinical practice.[8] Consequently, some students may struggle to make the shift from the classroom to the clinical setting, and seem to lack the ability to transfer the skills they have been taught into patient management.[3,4,9-11] The authors just cited propose that the difficulty may also be related to students’ lack of generic skills and professional behaviour. Their research on the skills required by physiotherapy and medical students to achieve success in clinical practice emphasises the need to balance core skills and knowledge of basic sciences against generic competencies. These generic skills include communication, interpersonal skills, awareness of one’s own attitudes,

a continued commitment to independent learning, the ability to adapt and change, and clinical reasoning.[4,9,12,13] The need for change in clinical education models, to ensure reinforcement of both the specific and generic skills needed for professional clinical practice, has been highlighted.[4] An area that has not received adequate attention is the extent to which students perceive themselves to be prepared to enter clinical practice for the first time. There is little published research as to whether they themselves are aware of areas in which they might have received inadequate preparation.[3,10] As there is a link between perceived competence in clinical skills and the ability to perform adequately with regard to patient management,[14,15] the students' perception of their own ability may be an important predictor of actual performance. The present article investigates physiotherapy students’ perceptions of their own readiness as they shift from a classroom foundation to clinical reality. It also aims to explain some of these perceptions with reference to the unique positioning of clinical educators within the University of Cape Town (UCT)’s Division of Physiotherapy’s framework. Traditionally, clinicians and academic staff have been responsible for the onsite clinical training of physiotherapy students. Rodger et al.[16] looked at clinical training across a range of allied healthcare disciplines, including physiotherapy, noting how changes in staffing at clinical sites, increasing student numbers, and diversification of the clinical platform have affected the ability of clinicians to support clinical education initiatives. As a result, universities have increasingly had to rely on contracted outside personnel to assist clinical training.[4] This approach, however, can be problematic. Such personnel often have very little paedagogical training, and input to students is varied

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Research and inconsistent, leading to high dissatisfaction levels.[17] This situation may be in contrast to permanent academic staff, who are increasingly being required to undergo training in educational skills.[1]

Context

At UCT, physiotherapy is offered as a 4-year Bachelor of Science degree within the Department of Health and Rehabilitation Sciences. A challenge facing the Division of Physiotherapy is to prepare students for the significant changes in healthcare delivery within the South African context, as highlighted by Shear et al.[18] The design of the undergraduate curriculum should balance the need to provide undergraduate students with a strong foundation in the basic sciences, appropriate physiotherapy-specific skills and techniques, as well as developing critical thinking and the necessary generic skills needed in clinical practice. Ultimately, the obligation of the physiotherapy curriculum is to prepare students for the workplace, which is practical, socially interactive and contextually varied.[7,11] The initial 2 years of the programme concentrate on the basic sciences and principles of physiotherapy. Clinical exposure starts in the second year, with weekly sessions of supervised group clinical work. From the third year of study, students work independently in a variety of clinical settings, rotating through general hospitals, paediatric sites, care of the elderly, neuromuscular skeletal (NMS) clinics and community areas. In their fourth and final year, students work increasingly fulltime in more complex clinical areas. Students require numerous skills to manage their own patient load at the different clinical sites. The theoretical, technical and generic skills needed are similar to those previously discussed by several authors.[4,9,13] For the purpose of this study, they have broadly been divided into: • theoretical knowledge • planning of an assessment and treatment • execution of an intervention • generic skills such as communication, time management, confidence and emotional readiness • overall sense of readiness, i.e. the students’ confidence that they are competent to practice at a third-year level. At each site, students are supported by weekly clinical educator visits. These teaching sessions guide students in applying the above skills. Since 2009 at UCT, permanent clinical educators have been appointed to academic posts to support clinical education. In addition to being responsible for facilitating learning in clinical settings, the clinical educators participate on an equal footing with academic lecturers in all departmental activities, including curriculum planning. At the end of every clinical rotation of a 5-week block, each student’s performance is evaluated by a clinical educator and a clinician. The evaluation takes the form of a practical exam on a patient and an overall block performance mark, together comprising a clinical mark for each student.

Objective

The aim of this study was to examine the extent to which 3rd-year physiotherapy students are adequately prepared for independent clinical practice. Both subjective and objective data were used. The study objectives, in 2 cohorts of 3rd-year physiotherapy students, were to: • determine whether the majority of students felt adequately prepared for their first independent clinical block • examine whether there was any difference in the median rating of students’ overall levels of preparedness across the different clinical placements

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•

establish links between assessment outcomes as evidenced by block marks and students’ perceived preparedness.

Method Design

This was a descriptive study utilising prospective student questionnaires to determine subjective perceptions and clinical test marks for the objective measures of performance.

Participants

The study took place over 2 years, with participants from 2 different cohorts of 3rd-year students being recruited. Students were asked to volunteer to participate in the questionnaire after being explained its purpose by the researchers, who were permanent clinical educators. Students repeating the 3rd-year clinical course were excluded from the study as only initial readiness for practice was being assessed.

Instrumentation

Questionnaire A self-developed questionnaire was used which consisted of 17 items related to key areas of novice competence. Items were chosen based on the literature[9,12,13] and the researchers’ own experiences in dealing with 3rd-year students entering clinical practice for the first time. The areas of readiness were broadly linked to the following components: • theoretical knowledge of conditions seen in the clinical placement • planning – which included questions on ability to obtain relevant information from patient folders, conduct a subjective and an objective evaluation, and identify and analyse patient problems • intervention – which included execution and adaptation of practical skills and decision-making on treatment length • generic competencies such as communication, time management, confidence and emotional readiness • measure of perceived overall readiness for practice. Answers were rated on a Likert scale from 1 to 5. The responses were made anonymously, but students were asked to provide their gender and in which clinical area they were placed. (There were 4 - 17 students in each placement, so identification of student responses was not possible.) A senior lecturer in the Education Development Unit, UCT, reviewed the questionnaire to ensure content validity. It was then piloted on 10 4th-year physiotherapy students. Feedback from the pilot study resulted in some minor grammatical changes being made.

Testing procedure

The questionnaire was administered in a lecture venue during the penultimate week of the first clinical block. Participants were informed of the purpose, benefits and risks of the study, as well as their right to withdraw at any stage. All participants completed an informed consent form (Appendices 1 and 2). Questionnaires were handed out and collected by the researchers, but there was no interaction between the students and the researchers after the procedure had been explained.

Ethical considerations

Ethical clearance for the study was obtained from the Human Research Ethics Committee of the Faculty of Health Sciences, UCT (HREC ref. 157/2012). Students were assured of anonymity and that the information obtained would

Research

Statistical analysis

Results from the 2 cohorts were amalgamated and entered into an Excel spreadsheet and imported into Statistica for analysis. The participants were grouped according to their first clinical block within one of the following areas: paediatrics, general hospital, NMS clinic, care of the elderly, and community. Descriptive statistics were used to describe the frequency of responses to each question. The internal consistency of the 17-item instrument was tested using Cronbach’s alpha and, as this was high, at 0.847, the individual scores were added together and the mean score calculated for each student. An independent t-test was then used to compare the results of the two cohorts, and ANOVA was used to establish if there was a significant difference in different areas of competency, student scores on the block performance mark and on the questionnaire, across the different clinical settings.

Results

Demographics of the sample

There were a total of 93 students entering clinical practice − 50 in the 1st and 43 in the 2nd cohort. However, as repeating students had been excluded and only volunteering 3rd-years were included as participants, a total of 67 students took part in the study. Forty-one respondents were female and 18 male. Eight participants failed to indicate gender. The number of respondents was highest in paediatric areas (17) and lowest in community placement (4) (Table 1). Students reported a median of 3 - 4 (moderate to good) preparation on every item (Table 2). They reported their own preparation for the block as good (median 4) and were confident in their ability to extract information from patients (median 4) and their folders (median 4). They were satisfied with their ability to communicate, both with

patients (median 4) and clinical staff (median 4), with 12 and 17 reporting excellent preparation in this area. Although their initial confidence levels were poor (median 2), these had improved to ‘good’ at the end of the block (median 4). The mean scores for each section and the total score indicated that the components related to theoretical understanding and generic competencies (affect) had the highest mean score, whereas the students scored themselves lowest in terms of overall preparedness for the block (Fig. 1). One-way ANOVA revealed that the students perceived that they were better prepared in some areas than others (F(4, 264) = 4.8601, p<0.001). Post hoc analysis indicated that the difference was between the higher affect (generic skills) scores and the lower perception of preparation for intervention and overall preparedness.

Comparison of total questionnaire scores across placements Although the scores in NMS were the highest, there were no significant differences between the mean scores of the different placements (F(4, 53)=0.804, p=0.528) (Fig. 2).

Mean score of clinical marks across the different clinical areas There was no significant difference between the mean scores of the clinical marks allocated to the first cohort of students (67.3±5.8) and the second

cohort (68.03±6.5; t=-.54, p=0.46). They were therefore amalgamated and ANOVA indicated that there was also no significant difference in the mean scores across the areas (F(4, 77)=0.438, p=0.781) (Fig. 3). (Note that the marks of all students were included in this analysis and not only those who filled in the questionnaire.)

Discussion

The results indicate a surprisingly high perception of preparedness, by the majority of students, on starting their first independent clinical block. This was contrary to the expectations of the authors and to much of the literature.[4,6,9,10,12,13] The scores are particularly high in the areas of communication with both patients and staff. It may seem contradictory that despite feeling prepared, the students’ confidence levels were low at the start of clinical block. However, it would be unlikely that students who had never treated patients would feel confident before entering the clinical arena. They appeared to gain considerable confidence over the course of the block. How realistic were the self-reports of clinical competencies? Some studies have linked the validity of self-reporting to actual ability.[19-21] In this study, it appears that the students did not overestimate their own ability as the cohort achieved similarly satisfactory clinical mark scores from all the clinical placements, with an average ranging from 65 - 68% − a ‘satisfactory’

74 73 72 71 70 69 68 %

be used by the researchers for the purpose of an article only.

67 66

Table 1. Placements attended by respondents on their first block

Placement

n (%)

Hospital

13 (19.4)

Paediatrics

17 (25.4)

Care of the elderly

11 (16.4)

Neuromuscular skeletal

13 (19.4)

Community

4 (6.0)

Missing information

9 (13.4)

Total

67 (100)

64 63

Theory

Planning

Intervention

Affect

Overall preparedness

Fig. 1. Means and 95% CIs of the mean scores of each component (n=58; 9 missing). There is a significant difference between the scores (p<0.001).

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Research

76 74 72 70

Total %

68 66 64 62 60 58 56 54

Hospital

Care of elderly Paediatrics

Community NMS

Fig. 2. Mean total scores per clinical placement area (n=58). (NMS = neuromuscular skeletal.) 78 76 74

Clinical mark

72 70 68 66 64 62 60

Hospitals

Paediatrics

Care of elderly

NMS

Community

Fig. 3. Clinical marks across the placements (N=78 as all 3rd-year students in the 2 cohorts were included).

performance, according to marking guidelines. However, it is impossible to correlate scores when the replies were anonymous, and there might have been individual discrepancies between perception and objective measurement. This sense of preparedness and competence can perhaps be attributed to an improved alignment between the taught curriculum and the needs of the

clinical arena, as discussed by other authors.[4,7,11] Students confirmed that they had adequate and appropriate theoretical knowledge to manage the pathologies encountered in clinical practice. This alignment has been supported by the inclusion of clinical educators within academic teaching clusters, at UCT. These clusters meet regularly to review course content and objectives. Input

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from clinical educators ensures that course content matches the health needs of the population, which students manage at clinical sites, as recommended by Stevens.[22] By facilitating the link between the students’ theoretical knowledge and its practical application, the clinical educators are able to build on the students’ ability to implement and manage an intervention.[4,23] Interestingly, most students reported a low sense of perceived overall preparedness on starting their first clinical block; but, when asked to rate their preparedness for specific competencies in theoretical knowledge, planning, intervention and even generic skills (affect), they reported adequate levels of preparedness. This rating might indicate that, despite being anxious on starting independent clinical practice, they felt supported by the clinical educators throughout the block, ensuring a safe learning environment in which to implement their knowledge and improve their confidence in their abilities, as suggested by a systematic review of education models.[17] Contrary to concerns in the literature that students were less prepared in terms of generic skills, the respondents reported a higher level of perceived competence in generic skills (affect) (with a mean score of just under 70%) than in areas of specific clinical competence in implementing an intervention (which has a mean score of just over 65%). Clinical educators are also ideally positioned as appropriate role models for students, by reinforcing professional behaviours and generic skills within the clinical arena,[24] which could explain the students’ confidence in these skills. The appointment of permanent academic clinical educators with additional training in educational skills[1] has resulted in a more standardised approach to supervision and a uniform understanding of the level of competence required to perform adequately within clinical practice at 3rd-year level. This conclusion is supported by the fact that there was no significant difference in students’ overall preparedness or the marks obtained, across the different clinical placements. Similarly, there was no difference in marks between the two different cohorts. The consistency of clinical marks speaks to similar expectations among UCT clinical educators. Fewer students were placed in the community block as this is a new placement. The large confidence intervals in both the total scores and the clinical block placements are indicative of the small number of respondents and the need to develop an appropriate assessment for performance in a nontraditional physiotherapy training setting.

Research Table 2. Perceived competency: Median scores obtained on each question (N=67) Non-existent (1)

Poor (2)

Moderate (3)

Good (4)

Excellent (5)

Median

Range

Overall preparedness for block

2-4

Own preparation before block

2-5

Theoretical knowledge of conditions encountered

1-5

Ability to obtain information from patient folder

2-5

Confidence in subjective evaluation

2-5

Ability to objectively assess patients

2-5

Ability to identify patient problems

2-5

Ability to identify appropriate interventions

2-4

Adequacy of practical skills

2-5

Application of practical skills

1-5

Ability to adapt physiotherapy treatment

2-5

Ability to decide on cessation of treatment

2-5

Ability to communicate with patient

1-5

Ability to communicate with clinical staff

1-5

Time management skills

2-5

Initial confidence levels

1-5

Confidence level at end of block

2-5

Emotional preparedness for block

1-5

Average number of responses in each category

0.4

7.7

27.8

26.8

4.1

Limitations of the study include the need to rely on self-reporting, which may produce biased results. In addition, the questionnaire was answered anonymously and consequently the responses could not be linked with the clinical performance marks. It might be that there is little correlation between perception of preparedness and objective clinical performance. It would appear that, in general, the students at UCT are given adequate training, preparation and support within the academic and clinical arenas, enabling them to perform competently when independently responsible for patient management for the first time.

Conclusion

According to the literature in clinical education, students often struggle to make the transition from the classroom to the clinical arena.[3,4,9-11] In contrast, this study demonstrates that 3rd-year physiotherapy students at UCT felt adequately prepared, across all aspects of clinical competencies, on their entry to clinical practice. The level of preparedness was not affected by which clinical setting they were sent to. This sense of preparedness was mirrored by their assessment marks, showing satisfactory averages across all clinical placements. This sense of readiness speaks to the alignment of the classroom curriculum and clinical expectations within the Division of Physiotherapy at UCT, implying that the basic sciences, technical and generic skills, and application of ideas taught during the 2 preclinical years do align with the needs of the client population, seen at clinical placements. The alignment has come about through extensive curriculum review, leading to both horizontal and vertical alignment across the years of training. This has coincided with the appointment of permanent clinical educators, each specialising in a particular field, as vital links between the classroom and the clinical setting, which could have enhanced the preparedness of physiotherapy students at UCT. We recommend that the integration of clinical and theoretical teaching be a major focus of physiotherapy training. The employment of academic, permanent clinical educators who, together with academic lecturers,

developed an appropriate curriculum has helped to bridge the gap between theory and clinical practice. References 1. Devlin M, Samarawickrema G. The criteria of effective teaching in a changing higher education context. Higher Education Research & Development 2010;29(2):111-124. [http://dx.doi.org/10.1080/07294360903244398] 2. Laitinen-Väänänen S, Talvitie U, Luukka M-R. Clinical supervision as an interaction between the clinical educator and the student. Physiother Theory Pract 2007;23(2):95-103. 3. Frantz JM, Rhoda AJ. Assessing clinical placements in a BSc physiotherapy program. Internet Journal of Allied Health Sciences and Practice 2007;5(3):1-6. 4. Strohschein J, Hagler P, May L. Assessing the need for change in clinical education practices. Phys Ther 2002;82(2):160-172. 5. Richardson B. The way forward – How and why ? Advances in Physiotherapy 1999;1(2):13-16. 6. Ernstzen DV, Bitzer E, Grimmer-Somers K. Physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: A case study. Medical Teacher 2009;31(3):102-115. [http://dx.doi.org/10.1080/01421590802512870] 7. Ramklass SS. An investigation into the alignment of a South African physiotherapy curriculum and the expectations of the healthcare system. Physiotherapy 2009;95(3):216-223. 8. Cross V. Begging to differ? Clinicians’ and academics’ views on desirable attributes for physiotherapy students on clinical placement. Assessment and Evaluation in Higher Education 1998;23(3):295-310. [http://dx.doi. org/10.1080/0260293980230306] 9. Clouten N, Homma M, Shimada R. Clinical education and cultural diversity in physical therapy: Clinical performance of minority student physical therapists and the expectations of clinical instructors. Physiother Theory Pract 2006;22(1):1-15. 10. Jones M, McIntyre J, Naylor S. Physiotherapy 2010;96(2):169-175. [http://dx.doi.org/10.1016/j.physio.2009.11.008] 11. Broberg C, Aars M, Beckmann K, et al. A conceptual framework for curriculum design in physiotherapy education – an international perspective. Eur J Physiother 2003;5(4):161-168. [http://dx.doi.org/10.1080/14038190310017598] 12. Cross V. The same but different. Physiotherapy 1999;85(1):28-39. 13. Dean SJ, Barratt AL, Hendry GD, Lyon PM. Preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. Med J Aust 2003;178(4):163-166. 14. Colbeck CL, Cabrera AF, Terenzini PT. Learning professional confidence: Linking teaching practices, students’ selfperceptions, and gender. The Review of Higher Education 2013;24(2):173-191. [http://dx.doi.org/10.1353/rhe.2000.0028] 15. Morgan PJ, Cleave-Hogg D. Comparison between medical students’ experience, confidence and competence. Med Educ 2002;36(6):534-539. 16. Rodger S, Webb G, Devitt L, Gilbert J, Wrightson P, McMeeken J. Clinical education and practice placements in the allied health professions: An international perspective. J Allied Health 2008;37(1):53-62. 17. Lekkas P, Larsen T, Kumar S, et al. No model of clinical education for physiotherapy students is superior to another: A systematic review. Aust J Physiother 2007;53(1):19-28. 18. Shear M, Sanders D, Van Niekerk R, Hobdell H, Reddy S. Education of health professionals for a restructured health system − whose responsibility should it be? S Afr Med J 1997;87(9):1104-1107. 19. Barnsley L, Lyon PM, Ralston SJ, et al. Clinical skills in junior medical officers: A comparison of self-reported confidence and observed competence. Med Educ 2004;38(4):358-367. 20. Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD. JAMA 1999;282(18):17371744. 21. Mabe P, West S. Validity of self-evaluation of ability: A review and meta-analysis. J Appl Psychol 1982;67(3):280-296. [http://dx.doi.org/10.1037/0021-9010.67.3.280] 22. Stevens DP, Kirkland KB. The role for clinician educators in implementing healthcare improvement. J Gen Intern Med 2010;Suppl 4:S639-643. [http://dx.doi.org/10.1007/s11606-010-1448-0] 23. Oyeyemi AY, Oyeyemi AL, Rufai AA, et al. Physiotherapy students’ perception of their teachers’ clinical teaching attributes. African Journal of Health Professions Education 2012;4(1):4-9. 24. Paice E, Heard S, Moss F. How important are role models in making good doctors? BMJ 2002;325(7366):707-710.

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Research Appendix 1 Information and informed consent form for students Dear Student General Information The study has been approved by the Faculty of Health Sciences Human Research Ethics Committee reference number 157/2012. The UCT clinical educators are attempting to improve the standard of clinical education by researching whether 3rd-year physiotherapy students are adequately prepared for clinical practice in their first clinical block. As part of the study, you will asked to complete an anonymous questionnaire. The questionnaire will be administered during one of your lecture periods during your fourth week of clinicals. In conjunction with the questionnaire, the researchers may need to access your marks from the 1st clinical block of 3rd year. The information obtained from this questionnaire will be used solely by the researchers for the completion of a journal article and will not be made available to other parties. Informed Consent I confirm that the exact procedures and possible complications of the above research have been explained to me. I understand that I may ask questions at any time during the data collection. I realise that I am free to withdraw from the study without prejudice at any time, should I choose to do so. I have been informed that all the information required by the researchers will be held in strict confidentiality, and will be revealed only as part of statistical analyses. I have carefully read this form. I understand the nature, purpose and procedure of this study. I agree to participate in this research project of the UCT clinical educators. Name (in full) of student: Signature: Date: Researchers:

Appendix 2 Questionnaire Please complete the following: Date of birth: Sex (male/female): Clinical block: Using the scale 1=non-existent, 2=poor, 3=moderate, 4= good, 5=excellent, please rate the comments below, by circling the number that best matches your opinion. 1. Rate your theoretical knowledge of the conditions you encountered on your first block

2. Rate your ability to obtain information from the patientâ&#x20AC;&#x2122;s folders within the designated time period

3. Rate the confidence with which you were able to conduct a subjective evaluation

4. Rate your ability to objectively assess your patients

5. Rate your ability to identify your patientâ&#x20AC;&#x2122;s problems

6. Rate your ability to identify appropriate interventions for the stated problems

7. Rate the adequacy of the range of practical skills you have been taught in the classroom.

8. Rate your ability to apply these practical skills when managing your patients on your first block

9. Rate your ability to adapt and/or cease physiotherapy treatment

10. Rate your ability to communicate effectively with the patients

11. Rate your communication with staff members at your clinical sites

12. Rate your time management while on the block

13. Rate your own preparation done before the block

14. Rate your initial confidence level in managing your first clinical block

15. Rate your confidence level towards the end of the block

16. Rate your emotional preparedness for managing situations faced on the first block

17. Rate your overall preparedness for the block

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Research PIQUE-ing an interest in curriculum renewal J Blitz,1 M Prax Med; N Kok,2 MPH; B van Heerden,2 MMed (Int); S van Schalkwyk,2 PhD 1

Division of Family Medicine and Primary Care, Stellenbosch University, Parow, South Africa

Centre for Health Professions Education, Stellenbosch University, Parow, South Africa

Corresponding author: J Blitz (juliablitz@sun.ac.za)

Background. The primary aim of undergraduate medical training at South African medical schools is to prepare the graduates adequately for internship. If we are to attain this objective, it is crucial to evaluate the ability of our graduates to cope with the demands of internship. Objective. To determine the extent to which first-year interns from Stellenbosch University (SU) considered that their undergraduate education prepared them for internship. Methods. The Preparedness for Internship Questionnaire (PIQUE) is based on Hill’s Preparation for Hospital Practice Questionnaire, with additional questions covering core competencies and exit outcomes that SU has determined for its medical curriculum. Participants were asked to respond to a series of statements preceded by ‘My undergraduate medical training prepared me to … ’, and also two open-ended questions. SU’s MB ChB graduates of 2011 (N=153) were invited to participate in the online survey. Results. Although the response rate was only 37%, graduates generally thought they had been well prepared for most mainstream clinical activities. However, there were areas in which respondents considered they could have been better prepared, specifically pharmacology, medicolegal work, minor surgery and the non-clinical roles that interns encounter. Conclusion. PIQUE appears to be a useful tool that can assist with curriculum renewal by highlighting areas that graduates feel they could be better prepared for. This challenges us to identify how curricula and teaching can be adjusted accordingly. AJHPE 2014;6(1):23-27. DOI:10.7196/AJHPE.318

Background

Medical education needs to prepare graduates for clinical practice by providing them with the basic clinical skills, knowledge and attitudes that they require once they commence their internship years.[1,2] Newly qualified medical graduates are required to progress swiftly from apprentices to practitioners as they move from the relatively protected academic environment to service in the public health system. In South Africa, this system is characterised by considerable variability in terms of resources and management. In recent years medical education has included a wide range of innovative teaching and learning approaches, particularly in the domain of clinical skills training.[3,4] Even if these innovations are typically based on sound pedagogical principles, it is necessary to evaluate their effectiveness. These studies often seek to obtain the perceptions of interns regarding the extent to which their undergraduate years prepared them for the internship experience.[3,4-7] While some of the studies adopt qualitative methods by conducting semi-structured interviews to elicit student perspectives,[8] a survey design to reach larger numbers of interns is a common approach. Evaluation studies provide insight into the intern’s experience and point to a number of generic issues. The first year of internship is often described as stressful. During this year interns are responsible for patient care, learn new skills and assist in procedures without prior experience.[1,2,6] Some interns find the application of their knowledge to practise rather challenging.[6] An Australian study reported that interns felt well prepared to conduct basic procedures, complete ward round documentation, complete routine patient assessment, request investigations, review ECGs and communicate with other staff.[7] However, this group described feeling less prepared for

handing over to night staff, managing medication and fluid status, assessing unstable patients, admitting patients and communicating with parents and families. Other studies describe how intern confidence in their skills increased over time,[6,8] while qualitative studies add a richer texture to the picture of preparedness as interns identified issues such as the ‘stress of transition’ and the difficulty of dealing with others, with uncertainty and with death.[8] These studies are strongly context bound, which raises questions as to their applicability in South Africa. In his 2002 study on community service (CS) for health professionals in South Africa, Reid[9] called for health sciences faculties ‘to address the gaps between the skills and attitudes of their graduates and the realities of the health of the South African public as experienced by community service professionals’. We would argue that the need to address these deficiencies includes the internship experience, which falls between formal studies and the CS year, and that South African studies investigate these gaps. Although there are broad guidelines with regard to what should be included in undergraduate medical curricula internationally,[10] and most countries have national guidelines or regulations such as those promulgated by the South African Minister of Health in consultation with the Health Professions Council of South Africa (HPCSA),[11] interns reflect the training that they received at the institutions at which they studied. The way in which curricula are conceptualised, the teaching approaches that are adopted (e.g. traditional models, problem-based learning, competency-based approaches), and the clinical training locations (e.g. academic hospitals, primary care clinics, rural schools), influence the student’s experience and, therefore, the intern’s sense of preparedness.

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Research The Profile of the Stellenbosch Doctor is articulated as follows: ‘ … doctors who have the knowledge, skills and attitudes to optimally utilise the opportunities available during the two-year internship so as to function autonomously in the primary health care sector thereafter, and who have acquired the ability and insight to develop further personally and professionally.’[12] In recent years the MB ChB programme at SU has undergone significant reform. These changes have consistently been informed by prevailing trends in medical education and the body of scholarship with regard to teaching, learning and assessment. This has resulted in changes to both the nature and structure of clinical exposure during the six years of the programme, and we considered it necessary to explore the extent to which our graduates feel prepared for internship. While we routinely evaluate all our programmes by student feedback, tracking the opinion of graduates occurs less frequently. Our research question was therefore to determine the extent to which our graduates felt prepared for internship. Our intention was twofold: to provide some validation for the ongoing curriculum renewal activities and to present a snapshot of the perceptions of our graduates at a particular point in their internship. We aimed to use the findings to inform decision-making with regard to future refinement of our curriculum.

Methods

A survey design was adopted. As this study was nested within a larger research project, ethical approval for the survey was obtained as part of the former study (HREC approval: N12/03/014). The Preparedness for Internship Questionnaire (PIQUE) was designed based on the Preparation for Hospital Practice Questionnaire (PHPQ) used by Hill et al.[2] in their 1998 study in Australia. To customise the questionnaire for our context, additional questions were included to ensure that we covered the range of core competencies that had been adopted by the faculty and the Profile of the Stellenbosch Doctor.[12] The final questionnaire comprised two sections. Section 1 asked the participants to respond to a series of 48 statements preceded by ‘My undergraduate medical training prepared me to … ’. It was emphasised that they were not being asked whether they were exposed to training in these areas, but rather how prepared

they considered themselves to carry out these functions/tasks (Appendix 1). A rubric was given to the participants for their scoring (Table 1). Section 2 of the questionnaire comprised two open-ended questions, asking interns to elaborate on three competencies that they believed they were particularly well prepared for and three competencies that they could have been better prepared for in their role as interns. Face validity was confirmed by five faculty experts. Changes were made based on comments and suggestions by the team. The questionnaire was translated into Afrikaans and the accuracy of the translation was checked by re-translating back into English. After piloting the survey with second-year interns (n=5) to assess validity, some of the questions were rephrased for clarity. After obtaining ethics approval, we sourced contact information for 153 of the 177 SU MB ChB graduates of 2011 who were in their first year of internship. An invitation to participate in the online survey was e-mailed to them. The survey was available from July to September 2012 using the university’s online web-based e-Survey

service. Up to four reminders were sent to nonresponders during the duration of the survey. A unique anonymised identifier was assigned to each respondent.

Results

The response rate was 37% (n=56). Responses were captured on an Excel spreadsheet. The Likert-scale questions were subjected to descriptive analysis, while the open-ended questions were organised thematically. Firstly, we calculated a mean overall preparedness score per intern (Fig. 1). Those who scored 4.5 or higher were deemed to be ‘fully prepared’. ‘Well prepared’ interns were placed between 3.5 and 4.4, and so forth. Importantly, there were no interns who felt less than ‘fairly well prepared’ across the full set of questions. The responses to each task were then analysed. For the purposes of reporting, responses of ‘fully prepared’ and ‘well prepared’ were combined as ‘well prepared’, while ‘a little prepared’ and ‘not prepared’ were combined as ‘less than adequately prepared’. We then reported on the tasks where the frequency of ‘well-prepared’ or ‘less than adequately

Fully prepared (mean score 4.5 - 5.0) Well prepared (means score 3.5 - 4.4) Fairly well prepared (mean score 2.5 - 3.4) A little prepared (mean score 1.5 - 2.4) Not prepared (mean score 1.0 - 1.4) 0

Interns (n)

Fig. 1. Number of interns per overall preparedness category.

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Table 1. Scoring rubric used in questionnaire 1

Not prepared

I did not know how to do this/I do not feel prepared to do this yet, even with supervision

A little prepared

I was rather unsure of how to do this/I needed someone to guide me through the process

Fairly well prepared

I was fairly sure of my ability/I was willing to try with some help

Well prepared

I felt that I knew how to do this/I could do this, but would have liked to have someone to check my work

Fully prepared

I knew how to do this really well/I felt able to do this well without any assistance

Research prepared’ was deemed to be significant by being more than one standard deviation above the mean. A significant number of interns thought that they had been ‘well prepared’ for the tasks listed in Fig. 2. Observing the score per task (potential range: 1 - 5), the mode was 5 for ‘carry out a comprehensive physical examination’, ‘carry out basic ward procedures (e.g. drips, catheters)’, ‘treat each patient as an individual’, and ‘approach senior staff for help when I feel uncertain’. Undergraduate training seems to be delivering on these important basic tasks. It also appears that training occurs in an environment in which students feel able to admit to being uncertain and to ask for help. Although the responses pointed more to preparedness than lack thereof, it is instructive to review those tasks for which a significant number of the interns felt ‘less than adequately prepared’ (Fig. 3). The task for which the greatest number of interns in the cohort felt ‘less than adequately prepared’ was knowing how to approach medicolegal documentation. When observing the tasks across the 5-point scale, however, there were only three tasks for which more than one or two interns felt that they had been ‘not at all prepared’. These were knowing what to do with medicolegal documentation (n=8), knowing their professional role and responsibility in the event of social protest (n=6), and selecting drugs on the basis of the cost versus risks and benefits (n=4). Of the 15 interns who had overall preparedness scores in the ‘fairly well prepared’ (lowest) category, the majority considered that they were ‘less than adequately prepared’ for the tasks set out in Fig. 4. The responses to the open-ended questions clarified issues for which the interns thought they could have been better prepared. These included: • small surgical procedures – dermatological and minor theatre procedures • emergency medicine – being responsible for a resuscitation • dealing with the workload – knowing how to triage patients, and time management • work relationships – conflict at work, dealing with differences of opinion • personal issues – stress management, life-work balance in the face of long hours • management of common conditions. These open-ended questions also provided additional information on what interns believed they were well prepared for. These included:

Carry out a comprehensive physical examination Carry out basic ward procedures (e.g drips, catheters) Approach senior staff for help when I feel uncertain Take responsibility for the care of the patient Maintain attitudes appropriate to the practice of my profession Appreciate the importance of group dynamics when working withing a team enviroment Draw up a comprehensive assessment of a patient 0

10 20 30 40 50 60 70 80 90 100 Respondents (%)

Well prepared

Fairly well prepared

Less than adequate preparedness

Fig. 2. Tasks for which a significant number of the respondents felt ‘well prepared’. Know what to with medicolegal documentation Justify drug uses on the basis of their mechanisms of action Select drugs on the basis of the cost while considering their risks and benefits Know my professional role and responsibility in the event of social protest Deal with relatives of patients in distressing situations Carry out basic surgical procedures Critically evaluate research as it relates to my clinical experience 0 Well prepared

Fairly well prepared

20 30 Respondents (%)

Less than adequate preparedness

Fig. 3. Tasks for which a significant number of respondents felt ‘less than adequately prepared’. Justifying drug uses on the basis of their mechanism of action Knowing what to do with the medicolegal documentation Dealing with relatives of patients in distressing situations Critically evaluating research as it relates to their clinical experience Feeling able to tell a patient that they have a terminal illness Selecting drugs on the basis of the cost versus their risks and benefits

Well prepared

Fairly well prepared

6 8 Interns (n)

Less than adequate preparedness

Fig. 4. Tasks for which the majority of fairly well-prepared interns (n=15) felt ‘less than adequately prepared’.

• working life – long hours and a good work ethic • confidence to do the ward work and make decisions

• advanced clinical abilities – drawing up a differential diagnosis and forming a management plan.

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Research Discussion

In general, graduates from SU considered that they had been well prepared for most mainstream clinical activities. However, there were also areas respondents thought they could have been better prepared for. These primarily included the domains of pharmacology, medicolegal work, minor surgery, and the non-clinical roles encountered by them. It is prudent to recognise that the aim of internship in South Africa, regulated by the HPCSA, is two years of additional experiential learning for MB ChB graduates. It can only be performed in HPCSA-accredited institutions and under the supervision of senior medical practitioners. Adequate completion of the internship requires proof of competence by supervisors and satisfactory completion of a standardised logbook designed by the HPCSA. It is, therefore, also recognised that certain knowledge and clinical skills and even attitudes could potentially be acquired during the internship years rather than during undergraduate medical training. This begs the question: Are there clear expectations of what training should be completed prior to internship, and what can be expected during this period? As some graduates are allocated to non-teaching hospitals for their internship, one can speculate whether the supervising staff are likely to teach the tasks in which the graduates thought they were less than adequately prepared. Although the response rate was only 37%, the findings of this study are reassuring as they suggest that medical graduates from SU perceive themselves to be adequately prepared for evaluating and managing individual patients, and for essential clinical duties and responsibilities associated with good patient care. Activities that a significant number of SU graduates considered themselves less than adequately prepared for mostly relate to administrative duties, but also to some important clinically related knowledge, skills and attitudes with regard to pharmacology, teamwork, breaking bad news, dealing with patients’ relatives, evidence-based medicine and quality improvement practice. The above findings may point towards opportunities for change in the content of the SU medical curriculum. Some of these issues have already been recognised and addressed, e.g. the introduction of clinical pharmacology and emergency medicine modules in the penultimate year of the six-year programme, as well as a longitudinal evidence-based healthcare theme extending over the entire curriculum. Recent international and national developments in health professions education are beginning to impact on South African training institutions and curricula.[13] These include the importance of transformative learning to aid our graduates in becoming leaders and change agents in the health system. Interdependence in education relates to, inter alia, the ability of SU graduates to function optimally in healthcare teams and as change agents.[14] The finding that 16% of this cohort of graduates felt less than adequately prepared to participate in activities that contribute to the effectiveness of the healthcare facility in which they worked, indicates a need for training change agents that are better prepared for such activities. More than 85% of the cohort, however, felt well prepared to appreciate the importance of group dynamics when working within a team. This seems to indicate that the emphasis we place on interdisciplinary education in the SU curriculum has the desired outcome. Our results suggest that it may be necessary to help clinician teachers to find ways to expose students to tasks such as completing medicolegal documentation and breaking bad news, as well as activities such as team

May 2014, Vol. 6, No. 1 AJHPE

dynamics and dealing with patients’ relatives. There may also have to be more opportunities for students to practise some of the basic procedures such as lumbar punctures and intercostal drain insertions while under the supervision of clinical teachers during undergraduate training.

Conclusion

The current international focus on the social accountability of medical schools has become important for the Medical and Dental Professions Board of the HPCSA. One of the main characteristics of a socially accountable training institution is its willingness to track its graduates and measure their performance after they leave the institution. This study is a first attempt at determining how well recent SU graduates are prepared for functioning as interns. However, it is not a trivial task to determine which outcomes should be achieved during undergraduate training and which should be left to the relatively unpredictable environment of internship training. One would assume that basic clinical competence in the management of common and emergency conditions is a definite prerequisite for entering internship. Other non-lifesaving competencies related to matters not directly linked to the care of individual patients and best learnt in an experiential manner, might be safely relegated to the period of internship training, assuming that this be under adequate supervision. Performing basic surgical procedures are skills that might best be learnt during internship – with adequate supervision and teaching skills. This highlights the need for ongoing discussion between universities and those responsible for internship supervision to clarify what each party can reasonably expect of the other. This survey highlights issues relevant to curriculum content. We should therefore ensure that curricular outcomes at SU include these tasks. As a team interested in faculty development, we also observe that there might be implications for ongoing professional development of clinicians as teachers. Many of the tasks for which the graduates believed they were less well prepared for are covered in existing curricular outcomes and most are part of everyday practice in any clinical training environment. This survey has provided insight into areas that could be pursued in helping clinician teachers to instruct students more effectively regarding tasks that they feel inadequately prepared for. PIQUE appears to be a tool that can help with measuring the preparedness of medical graduates for their internship and for assisting with the ongoing renewal of curricula by highlighting areas for which SU graduates feel they could have been better prepared. As many of these appear to be in nonclinical areas, it challenges us to identify which elements of curriculum renewal are required to ensure that our graduates are well prepared for most of what awaits them in internship. Acknowledgements. The researchers gratefully acknowledge funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR) through Health Resources and Services Administration (HRSA) under the terms of T84HA21652 via the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI). The researchers further acknowledge the contributions made by the rest of the RCS Longitudinal study team: Professors M de Villiers, J Bezuidenhout and H Conradie and Dr T Fish, as well as Martie van Heusden and Sam van Rensburg for translating and verifying the Afrikaans version of the questionnaire.

Research References

1. Abuhusain H, Chotirmall SH, Hamid N, O’Neill SJ. Prepared for Internship? Ir Med J 2009;102:82-84. http://www.imj.ie// ViewArticleDetails.aspx?ArticleID=3304 (accessed 10 October 2012). 2. Hill J, Rolfe IE, Pearson S, Heathcote A. Do junior doctors feel they are prepared for hospital practice? A study of graduates from traditional and non-traditional medical schools. Med Educ 1998;32:19-24. 3. Millan LPB, Semer B, Rodrigues JM, Gianini RJ. Traditional learning and problem-based learning: Self-perception of preparedness for internship. Revista da Associação Médica Brasileira 2012;58:594-599. [http://dx.doi.org/10.1590/S010442302012000500018] 4. Scicluna HA, Grimm MC, O’Sullivan AJ, et al. Clinical capabilities of graduates of an outcomes-based integrated medical program. BMC Medical Education 2012;12:23. [http://dx.doi.org/10.1186/1472-6920-12-23] 5. Cave J, Goldacre M, Lambert T, Woolf K, Jones A, Dacre J. Newly qualified doctors’ views about whether their medical school had trained them well: Questionnaire surveys. BMC Medical Education 2007;7:38. [http://dx.doi. org/10.1186/1472-6920-7-38] 6. Gome JJ, Paltridge D, Inder WJ. Review of intern preparedness and education experiences in general medicine. Internal Medicine Journal 2008;38:249-253. [http://dx.doi.org/10.1111/j.1445-5994.2007.01502.x] 7. Kelly C, Noonan CLF, Monagle JP. Preparedness for internship: A survey of new interns in a large Victorian Health Service. Australian Health Review 2011;35:146-151. [http://dx.doi.org/10.1071/AH10885]

8. Brennan N, Corrigan O, Allard J, et al. The transition from medical student to junior doctor: Today’s experiences of tomorrow’s doctors. Med Educ 2010;44:449-458. [http://dx.doi.org/10.1111/j.1365-2923.2009.03604.x] 9. Reid SJ. Community service for health professionals. In: Ijumba P, Ntuli A, Barron P, eds. South African Health Review. Durban: Health Systems Trust, 2002:136-160. 10. World Federation for Medical Education. Basic Medical Education. Denmark: WFME Office, 2012. 11. Health Professions Council of South Africa. Health Professions Act 56 of 1974. Regulations relating to the registration of students, undergraduate curricula and professional examinations in medicine. Government Gazette 31886, 19 February 2009. 12. Faculty of Medicine and Health Sciences, Stellenbosch University. The Profile of the Stellenbosch Doctor. http:// sun025.sun.ac.za/portal/page/portal/Health_Sciences/English/New%20Education/MBChB/Profiel%20nuwe%20 kurrikulum%20finaal.pdf (accessed 5 March 2013). 13. Van Heerden BB. Effectively addressing the health needs of South Africa’s population: The role of health professions education in the 21st century. S Afr Med J 2013;103:21-22. [http://dx.doi.org/10.7196/SAMJ.6463] 14. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958. [http://dx.doi.org/10.1016/S01406736(10)61854-5]

Appendix 1. Preparedness for internship questionnaire

Appendix 1 (continued). Preparedness for internship questionnaire

My undergraduate medical training prepared me to:

1. Handle most clinical emergencies 2. Cope with stress caused by my work

27. Appreciate the importance of group dynamics when working within a team environment

3. Recognise my own clinical limitations

28. Know how to prioritise my day`s activities

4. Carry out basic surgical procedures

29. Select drugs on the basis of the cost versus their risks and benefits

5. Discuss health risk behaviours with patients

30. Participate in activities that contribute to the effectiveness of the healthcare facility in which I work

6. Maintain attitudes appropriate to the practice of my profession 7. Cope with my own emotions in distressing clinical situations 8. Evaluate the impact of family factors on illness

31. Feel competent to counsel a distressed patient 32. Record clinical data systematically 33. Be sensitive to the needs of nursing staff

9. Discuss relevant preventive health strategies with patients

34. Provide education to patients

10. Serve in administration and leadership roles if necessary 11. Carry out basic ward procedures (e.g. drips, catheters) 12. Justify drug uses on the basis of their mechanisms of action 13. Continually evaluate my own performance

35. Demonstrate efficient and appropriate use of diagnostic procedural skills 36. Treat each patient as an individual 37. Deal with dying patients

14. Draw up a comprehensive assessment of a patient

38. Approach senior staff for help when I feel uncertain

15. Understand the interaction of social factors with disease 16. Appreciate the importance of a patient’s cultural/ethnic background 17. Balance my work and personal life

39. Identify my own learning needs 40. Critically evaluate research as it relates to my clinical practice 41. Co-ordinate a comprehensive patient management plan with allied health professionals (e.g. physiotherapists)

18.Take responsibility for the care of the patient 19. Apply my knowledge of basic sciences to clinical conditions 20. Manage ‘difficult’ patients

42. Know my professional role and responsibility in the event of social protest

21. Appreciate the impact of poverty and unemployment on illness

43. Know how to approach ethical dilemmas

22. Feel able to tell a patient that they have a terminal illness

44. Deal with my emotion when a patient of mine dies

23. Evaluate my learning experience

45. Know what to do with medicolegal documentation

24. Carry out a comprehensive physical examination

46. Function effectively in a resource-constrained environment

25. Behave in a calm manner in difficult situations

47. Know how to respond to the healthcare needs of the community within which I have been placed

26. Invest time in developing my skills

continued...

48. Deal with relatives of patients in distressing situations

May 2014, Vol. 6, No. 1 AJHPE

Research Student doctors (umfundi wobugqirha): The role of student-run free clinics in medical education in Cape Town, South Africa S C Mendelsohn, MB ChB Rob Ferreira Hospital, Nelspruit, Mpumalanga, South Africa Corresponding author: S C Mendelsohn (simonmendelsohn@gmail.com)

Background. Since 1943, the Students’ Health and Welfare Centres Organisation (SHAWCO) of the University of Cape Town has provided voluntary, student-run free clinics in under-served communities in Cape Town, South Africa, filling major gaps in the city’s healthcare services. Objective. To determine the role SHAWCO clinics play in medical education. Methods. A mixed-methods study with a predominantly quantitative questionnaire utilising dichotomised Likert scales was performed with 110 clinic volunteers. The Likert scales were converted to population proportions for quantitative analysis. Qualitative data obtained from participants’ comments were analysed thematically. Discussion. SHAWCO clinics provide a controlled environment in which to practise skills acquired in medical school. Over 98% of students attend clinics to increase their clinical exposure. Medical conditions that students encounter are primary care problems, often neglected at tertiary level teaching institutions. The clinics achieve what the formal curriculum struggles to do: humanise medical treatment, allowing one to better understand the socio-economic background of patients. Conclusion. SHAWCO is best suited in its current role of hands-on, community-based learning to augment the training provided in the formal medical curriculum. AJHPE 2014;6(1):28-32. DOI:10.7196/AJHPE.311

The City of Cape Town, South Africa is home to an estimated population of 3.5 million, >15% of whom live in informal housing or shanty towns.[1] These dwellings often do not have piped water or access to flushing toilets, and many are still dependent on bucket latrines. According to the 2007 South African census, only 20.9% of people living in the Cape Town area have completed their final year of high school, and there is an unemployment rate of 24.5%. The city faces a quadruple burden of disease, which includes high levels of infectious diseases (HIV/AIDS/TB and other sexually transmitted infections); a growing prevalence of noncommunicable diseases (diabetes, hypertension); high maternal, infant and child mortality rates; and social conditions linked to excessive levels of interpersonal violence and injuries. Volunteers from the Students’ Health and Welfare Centres Organisation (SHAWCO), based at the University of Cape Town (UCT), run free primary healthcare clinics in the evenings. SHAWCO manages seven weekly student-run primary healthcare clinics in several under-served Cape Town communities. Crèches (day-care facilities) and primary schools are also visited on a weekly basis and provide preventive care to children in under-privileged communities. SHAWCO maintains a close relationship with UCT’s Faculty of Health Sciences, and runs clinics in partnership with, among others, the School of Child and Adolescent Health. SHAWCO clinics were started by concerned medical students and faculty members in the early 1940s in response to large numbers of poor migrant labourers seeking work in Cape Town. The latter were forced to live in rapidly growing shanty towns, without access to basic amenities or healthcare facilities.[2] Initially, SHAWCO provided both healthcare and social welfare services. During the Apartheid years,

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SHAWCO continued with its activities in the townships, despite opposition from the state. The clinics were often the only form of healthcare available in these areas. Currently, over 500 medical and allied health sciences students continue to deliver free primary healthcare to over 4 000 people in under-resourced and under-served communities throughout Cape Town annually. During clinic hours, patients are examined and treated by medical students from UCT, who are supervised by volunteer doctors from public hospitals and private practices. Students in their clinical years (years 4 - 6) are responsible for clerking and managing patients, while simultaneously training preclinical students (years 1 - 3).

SHAWCO and health sciences education

In an article in a 1963 edition of the SAMJ,[3] Dr Golda Selzer, a co-founder of SHAWCO, writes that this organisation provides students with experience in a range of clinical problems and conditions rarely seen in highly specialised teaching hospitals, but that are the mainstay of general practice. The community-based approach of SHAWCO tackles aspects of general medical practice that cannot be dealt with at tertiary hospitals.[2] Katz[4] alludes to the multiple educational benefits of SHAWCO, including knowledge gained regarding the manifestations and treatment of common ailments, the application of knowledge gained during formal education in a practical training ground, and the ability to distinguish minor complaints from serious ones. In addition, Katz writes that the clinical environment of SHAWCO ‘enables the student to handle a patient with ease, enhancing the doctor-patient relationship’. The article concludes that the knowledge gained and the increased appreciation of patients’ medical and social problems better prepare these students for clinical medicine.

Research Role of student-run clinics in medical education

A number of studies demonstrate that student-run clinics, in addition to benefiting local under-serviced communities, also play a significant role in medical education, filling the primary healthcare gap not addressed by tertiary hospitals. [5-8] The autonomous nature of student-run clinics promotes student-directed learning, more humanistic learning and patient care.[8] Students learn and practise many skills while working in the clinics, including taking a history, examining patients, formulating assessments and managing, while also gaining an understanding of important biopsychosocial issues.[6,9-11] The clinics also provide students with administrative and health management training – an aspect omitted in their health sciences education. [8,12-14] Many student-run clinics offer multidisciplinary team-based care, which provides an ideal context for fostering a team relationship. Some studies conclude that the early clinical experience helps students to develop confidence and a positive attitude towards their medical studies and future careers.[6] Students who have had early clinical contact are also more likely to pursue careers in primary care, become more socially responsive and show a greater interest in rural health.[11] There is good evidence that the quality of care delivered at student-run clinics is as good as or better than healthcare managed and delivered by qualified professionals,[8] and that patients are satisfied with the service.[15] The aim of this study was to determine the role of student-run free clinics in medical education at UCT.

Research questions

• What are the educational benefits of studentrun free clinics? • What do medical students gain from working in the clinics that they would not gain from their formal medical training? • Why do medical students attend the clinics? • What form of educational platform do the clinics provide?

Methods

Study design

This was a cross-sectional mixed-methods (primarily quantitative) study done by means of a questionnaire and analysis of the SHAWCO patient and student-volunteer databases.

Ethical considerations

Ethics approval for use of the SHAWCO databases and questionnaires was obtained from the UCT Research Ethics Committee (REC-REF:187/2010). All data were anonymous and informed consent was obtained from all participants.

Instruments used

A standardised quantitative questionnaire with dichotomised Likert scales was used, with the option of providing additional comments for each question. Some of the questions are the same as or similar to those used by Simpson and Long,[5] but have been adapted to the South African context. The full questions are provided in the results section of this article. During a pilot study, the questionnaire was administered to 10 regular SHAWCO volunteers. The study appears to have good construct validity: the students all agreed that the questions were clear. Reliability was estimated using the ‘test/ re-test’ method, i.e. 3 participants completed the same questionnaire on two different occasions. There was a high positive correlation between original and repeat survey results (r=0.9) and the study was shown to be repeatable and generalisable. The concepts were well defined and explained before being measured. Questionnaires were proofread and reworded to make them easy to understand, with no chance of misunderstanding.

Sample

A non-randomised convenience sample of students in all years of study (Fig. 2) was obtained, with 110 questionnaires captured from available volunteers at SHAWCO clinics during a 1-month period in 2010. Using a 95% confidence interval (CI), the sample population needed to be n>61 to yield results of statistical significance. Answer saturation was attained with qualitative questions.

Data analysis

Data were cleaned and analysed using Microsoft Excel 2003 software. Results of the dichotomised Likert scales were converted to population proportions. The adjusted Wald method was used to calculate CIs for population proportions. Thematic analysis was used for qualitative data obtained from participants’ comments.

Results

SHAWCO patient population

The SHAWCO database captured 4 267 patients in 2010, over two-thirds of whom were female.

8 6th year 18

Study population

The study population consisted of health science students at UCT (N=668) who had volunteered to work in SHAWCO clinics (Fig.1). This study population represents approximately 39.1% of the total health sciences campus student population.

5th year 4th year 3rd year 2nd year 1st year

2 Clinical

Pre-clinical

Fig. 2. Student participants by year of study.

48; 7% 102; 15% 278; 42%

Pre-clinical medical students Clinical medical students International/visiting medical students Allied health professions students

240; 36%

Fig. 1. Total student volunteers.

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Research

1 800

173; 4.05%

Urological/male

415; 9.73%

88; 2.06%

Orthopaedics/ rheumatology Respiratory and ear, nose and throat Trauma

Ophthalmological

159; 3.73%

52; 1.22%

Neurological

Psychological

40; 0.94%

Haematological 14; 0.33%

Infectious diseases

640; 15.00%

Endocrine

Gastrointestinal tract Gynaecological

28; 0.66%

448; 10.50%

705; 16.52%

None

Cardiovascular

Dental 19; 0.45%

200

Dermatological

400

195; 4.57%

800 600

111; 2.60%

Patients, n

1 200 1 000

47; 1.10%

1 625; 38.09%

1 600 1 400

Fig. 3. Patient diagnosis statistics.

The patients ranged from 2 weeks to 91 years of age, with the largest grouping <18 years of age (39.37%). The majority of patients presented with infectious diseases, often associated with poor living conditions, lack of basic services and the HIV/ TB co-epidemic. The six leading diagnoses (Fig. 3) were upper respiratory tract infections (20.98% of all patients), backache (5.60%), lower respiratory tract infections (5.48%), suspected or confirmed worm infestations (5.44%), sexually transmitted diseases/infections (5.39%) and acute diarrhoea (4.76%).

Educational benefits of attending clinics

Many students learn a variety of new skills for the first time in SHAWCO clinics (Table 1), including basic side-room investigations and clerical skills. Many skills that are taught as part of the medical curriculum are later practised in SHAWCO clinics (Fig. 4), as one respondent wrote: ‘SHAWCO clinics allow me to put into practice the copious amounts of theory being learned and make it more relevant to what I am doing.’ Several students also mentioned using clinics as an opportunity to practise their language skills (n=11), specifically Afrikaans and isiXhosa. Tables 2 and 3 summarise what students perceive to be the benefits of attending SHAWCO clinics.

Teaching

Fig. 4. Patients queue outside a SHAWCO clinic in Cape Town, South Africa.

Table 1. What skills did you learn for the first time in SHAWCO clinics? Skills

Student volunteers (N=110), % (CI (%))

Completing a referral letter or medical certificate

63.64 (54.32 - 72.04)

Taking a patient history

58.18 (48.84 - 66.98)

Presenting patients to the doctor

57.27 (47.93 - 66.12)

Performing physical examinations

56.36 (47.03 - 65.26)

Performing a pregnancy test and counselling

56.36 (47.03 - 65.26)

Filling in a legal prescription

53.64 (44.35 - 62.68)

Managing/treating patients

52.73 (43.46 - 61.81)

Performing health promotion/education

42.73 (33.88 - 52.07)

Testing blood glucose with a visidex

38.18 (29.64 - 47.52)

Using an otoscope or ophthalmoscope

34.55 (26.3 - 43.83)

Using a stethoscope, reflex hammer or taking blood pressure

31.82 (23.83 - 41.03)

Testing haemoglobin with a haemoglobinometer

24.55 (17.41 - 33.4)

SHAWCO = Students’ Health and Welfare Centres Organisation of the University of Cape Town; CI = confidence interval.

Whereas pre-clinical students are predominantly taught by students in their clinical years (83.82%), the latter receive more teaching from volunteer doctors (77.50%) and less from their peers (61.54%). One volunteer responded as follows: ‘The clinics allow us as students to assist those in the years below us develop the skills that we were so privileged to learn during our SHAWCO experiences. The whole self teach thing works, if it is voluntary and practical … [and] not in a tutorial room!’

The majority of students attend clinics to spend time with patients and get hands-on exposure (98.18%): ‘We were actually responsible for the appropriate treatment and management of patients for the first time.’ ‘I want to do primary care when I graduate. We don’t get enough clinical exposure to primary level problems in our curriculum.’

Why do students attend SHAWCO clinics?

Benefits of student-run free clinics

Most students attend clinics ‘to serve the poor’ (93.58%) or because of enjoyment (93.64%), as one participant wrote: ‘Being a first year, SHAWCO is what brought excitement to my medical school life because we don’t do anything practical … I like them maybe because they’re not compulsory: I go because I want to.’

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Discussion

SHAWCO clinics have several benefits over government-run clinics. Student volunteers identified these benefits, which include more time to address patients’ needs (allowing a higher quality of care), shorter waiting times (resulting in greater patient satisfaction), and free care and treatment. A respondent wrote:

Research

Table 2. Do you feel that attending SHAWCO clinics … Student volunteers (N=110), % (CI (%)) Allows you to better understand the socioeconomic background of patients in our society?

89.18 (87.39 - 90.74)

Makes you more confident in interviewing or examining patients?

88.73 (86.92 - 90.32 )

Shows you the practical relevance of what you are studying and makes it easier to study?

87.06 (85.14 - 88.76)

Helps you to learn things that could not be gathered from books?

84.22 (82.16 - 86.08)

Humanises the medical treatment of disadvantaged people?

82.87 (80.75 - 84.80)

Reminds you why you are studying medicine?

77.99 (75.68 - 80.13)

Improves your health management and logistical skills?

76.71 (74.36 - 78.90)

Has improved your knowledge of South Africa’s medical system?

69.95 (67.43 - 72.35)

Promotes the multidisciplinary team relationship?

47.56 (44.89 - 50.24)

Table 3. Why do I volunteer for SHAWCO clinics? Student volunteers (N=110), % (CI (%)) To spend time with patients/get hands-on exposure

98.18 (93.21 - 99.91)

I enjoy myself at clinics

93.64 (87.23 - 97.1)

To serve the poor

93.58 (87.12 - 97.07)

To learn clinical skills

85.45 (7.57 - 90.95)

Because I don’t get enough clinical (hands-on) exposure as part of my academic course/these clinics fill this gap in the curriculum

66.06 (56.74 - 74.28)

To spend time with friends

56.36 (47.03 - 65.26)

Enhance my resume/curriculum vitae

36.70 (28.23 - 46.07)

To receive rewards/gifts

5.45 (2.28 - 11.63)

‘ We deliver care within the community – we get to know the members of the community within their cultural context – we use what they have taught us to come up with culturally/contextually-appropriate treatment plans. We are given the opportunity of time to address ALL the patients’ needs.’

Situated learning at SHAWCO

The leading diagnoses at student-run free clinics in First World countries appear to be diseases of lifestyle and urban environment, i.e. hypertension, diabetes, hyperlipidaemia, depression and asthma.[12,13] This is in contrast to the diagnoses at SHAWCO clinics in the South African context, where infectious diseases (respiratory and gastrointestinal) related to living conditions and the HIV/AIDS/TB pandemic predominate. Despite the majority of patients having primary care problems, medical training is conducted in secondary and tertiary hospitals; consequently, such problems

are often neglected. The clinics expose students to appropriate primary healthcare conditions that they will frequently encounter during their internship and community service years. The SHAWCO experience provides hands-on clinical experience that enhances the learning of students, and additional health management/ administrative skills lacking in our healthcare system. Although elements of SHAWCO have been incorporated into the UCT medical school curriculum, it does not qualify as a service-learning experience, i.e. students do not reflect upon their experiences in the formal clinics and there are no learning outcomes or core competencies. Perhaps SHAWCO and other student-run clinics are better suited in their current role of providing a platform for learning situated in the community as an adjunct to formal university medical education. They provide a controlled environment in which to practise skills learned during medical training. This is the concept of situated learning (learning taking place in the same context in which it is applied), first proposed by Lave and Wenger.[16] The clinics also offer an opportunity to integrate language training into the curriculum (specifically isiXhosa and Afrikaans), as one respondent wrote: ‘I attend the SHAWCO Masiphumelele Clinic, and a significant proportion of patients speak isiXhosa as a first language, MAYBE some English. Thus, it has impressed upon me the importance of being able to effectively and understandably converse with these patients in isiXhosa. SHAWCO always allows me to practise my isiXhosa, and my skill in the language has definitely improved as a result of attendance of the clinics.’

Why do students attend student-run free clinics?

‘ You initially learn clinical skills in the tertiary level teaching hospital where the patients are complicated and are tired of seeing so many students. I used to hate going up to patients as a second or third year where your practicing does nothing to help them and they are irritated because you are the millionth student come to see them. At SHAWCO clinics, you don’t feel bad about practicing your clinical skills on them because you are actually being useful and your examination contributes towards the diagnosis and management of the patient instead of it only benefiting you.’ By attending SHAWCO clinics, students gain clinical exposure and confidence, practise clinical skills, and gain skills that cannot be learnt in a lecture room setting, including administrative and logistics skills. The results indicate that a more hands-on training is more appreciated by students.

Community of practice

The concept of a community of practice, a group that shares a similar occupation and interests, was first postulated by Lave and Wenger[16] and can be seen in the SHAWCO community. The clinics offer a unique opportunity for senior students to tutor junior students by passing on their knowledge. This peer-to-peer teaching is often easier for students. They may attend clinics, as they feel a sense of belonging or a connection to similar medical professionals who all have similar ideals and interests. This group provides motivation and a sense of importance to the students. Some comments by participants illustrate this idea: ‘I really enjoy the interaction with the patients, hearing their stories. I really appreciate that they let us all learn from them, but it seems that they appreciate us too ... It makes me so excited to be doing this course. Working at SHAWCO reminds me of the things that make all the theory that we have to slog through worth while!’

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Research Making clinical practice a fun experience: It is also clearly evident from the respondents’ comments that the clinics motivate and encourage them. In short, they are fun. They give students a sense of purpose and achievement, and a desire to persevere with the degree programme.

Humanistic care and biopsychosocial context

The SHAWCO experience makes volunteers feel that they have made a difference and positively reinforces their altruistic reasons for becoming doctors. This is very important as many feel that the medical school experience has become dehumanising for both patient and student. The clinics teach the students an holistic approach to managing patients. As one volunteer wrote: ‘The most important thing I learned from SHAWCO was the influence of social problems on people’s health and well-being. (Something that is largely ignored in clinical medicine curriculum).’ ‘It has also opened [my eyes] into other peoples’ worlds and background, which has taught me a lot about how different cultures perceive certain diseases.’

Pitfalls of student-run free clinics

Free clinics are perpetually under-resourced, which creates challenges, i.e. insufficient supervision and under-treatment of patients. As a result of learning from peers and inexperienced physicians, students may also acquire poor clinical practices (‘bad habits’). Some weaknesses identified by study participants include a lack of certain essential services at the clinics, insufficient access to psychosocial services, and poor continuity of care (patients are often seen by different students and doctors on a return visit to the SHAWCO clinic, resulting in poorer treatment outcomes). The clinics teach these important realities of healthcare in the South African context to future patient advocates and healthcare leaders.

Conclusion

SHAWCO student-run clinics play an integral role in primary healthcare education at UCT’s Faculty of Health Sciences by increasing clinical exposure, confidence, skills and knowledge of medical students. These clinics achieve what the medical curriculum struggles to do: humanise medical treatment, allowing one to better understand the socio-economic background of patients. This author recommends that student-run free clinics at medical schools throughout South Africa would serve as ideal

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platforms for situated learning, while simultaneously fulfilling the social responsibility obligations of the medical institutions.

Future research opportunities

There are several research opportunities available to explore, e.g. how do student-run free clinics influence future career choice: are volunteers more likely to work in rural settings once qualified, or stay in Africa? Another avenue of research to assess the educational role of student-run free clinics would be to compare the quality of patient care from doctors who attended free clinics with that of colleagues who did not. A future study could also ascertain where students acquired knowledge, confidence and clinical skills, comparing SHAWCO volunteers with other medical students. There are currently no data comparing the quality of care received at student-run to government clinics in South Africa and limited research on the quality of care received at student-run clinics in general. Acknowledgement. I would like to thank Dr George Draper for his supervision during this study. References 1. Statistics South Africa. Community Survey, 2007. South Africa: Statistics South Africa, 2007. 2. Favara DM, Mendelsohn SC. The Students’ Health and Welfare Centres Organisation (SHAWCO) of the University of Cape Town: A review of the past 69 years. S Afr Med J 2012;102(6):400-402. 3. Selzer G. SHAWCO: The Students’ Health and Welfare Centres Organisation of the University of Cape Town. S Afr Med J 1963;37:58-59. 4. Katz D. The Students’ Health and Welfare Centre (SHAWCO), University of Cape Town, South Africa. Br J Med Educ 1967;1(3):178-182. 5. Simpson SA, Long JA. Medical student-run health clinics: Important contributors to patient care and medical education. J Gen Intern Med 2007;22:352-56. [http://dx.doi.org/10.1007/s11606-006-0073-4] 6. Batra P, Chertok JS, Fisher CE, et al. The Columbia-Harlem homeless medical partnership: A new model for learning in the service of those in medical need. Journal of Urban Health: Bull N Y Acad Med 2009;86(5):781790. [http://dx.doi.org/10.1007/s11524-009-9386-z] 7. Clark DL, Melillo A, Wallace D, et al. A multidisciplinary, learner-centered, student-run clinic for the homeless. Fam Med 2003;35(6):394-397. 8. Meah YS, Smith EL, Thomas DC. Student-run health clinic: Novel arena to educate medical students on systemsbased practice. Mt Sinai J Med 2009;76:344-356. [http://dx.doi.org/10.1002%2Fmsj.20128] 9. Cooper HC, Gibbs TJ, Brown L. Community-orientated medical education: Extending the boundaries. Med Teach 2001;23:295-299. [http://dx.doi.org/10.1080%2F01421590120043071] 10. Davenport BA. Witnessing and the medical gaze: How medical students learn to see at a free clinic for the homeless. Med Anthropol Q 2000;14:310-327. [http://dx.doi.org/10.1525%2Fmaq.2000.14.3.310] 11. Littlewood S, Ypinazar V, Margolis SA, et al. Early practical experience and the social responsiveness of clinical education: Systematic review. Br Med J 2005;331:387-391. [http://dx.doi.org/10.1136%2Fbmj.331.7513.387] 12. Beck E. The UCSD Student-Run Free Clinic Project: Transdisciplinary health professional education. J Healthcare Poor Underserved 2005;16(2):207-219. [http://dx.doi.org/10.1353%2Fhpu.2005.0026] 13. Jimenez M, Tan-Billet J, Babineau J, et al. The promise clinic. A service learning approach to increasing access to healthcare. J Healthcare Poor Underserved 2008;19:933-943. [http://dx.doi.org/10.1353/hpu.0.0046] 14. O’Connell MT, Rivo ML, Mechaber A, et al. A curriculum in systems-based care; experiential learning changes in student knowledge and attitudes. Fam Med 2004;36(suppl):S98-S104. 15. Ellett JD, Campbell JA, Gonsalves WC. Patient satisfaction in a student-run free medical clinic. Fam Med 2010;42(1):16-18. 16. Lave J, Wenger E. Situated Learning – Legitimate Peripheral Participation. Cambridge: Cambridge University Press, 1991.

Research Problem-solving abilities of radiography students at a South African university T Pieterse,1 MTech (Radiography); H Lawrence,1 DTech (Radiography); H Friedrich-Nel,2 PhD (Health Professions Education) 1

Department of Radiography, University of Johannesburg, South Africa

Central University of Technology, Bloemfontein, South Africa

Corresponding author: T Pieterse (traceyp@uj.ac.za)

Background. Developing the problem-solving skills of student radiographers is imperative for encouraging critical thinking and allowing them to work efficiently in an era of rapidly advancing technology. Studentsâ&#x20AC;&#x2122; ability to demonstrate these skills was studied so that the Department of Radiography, at a comprehensive university in South Africa, could develop a more explicit curriculum to facilitate these competencies. Objective. To assess problem-solving skills of third-year radiography students at a comprehensive South African university. Methods. The study employed a descriptive exploratory design. The participantsâ&#x20AC;&#x2122; responses to vignettes (in the form of clinical scenarios) were analysed using a Likert scale and action verbs developed for evaluating evidence of problem-solving skills and providing quantitative data. Field notes were made while analysing responses to each question, providing qualitative data. Results. The findings indicate that the majority of participants demonstrated a minimal ability to problem solve in a vignette. This implies that to improve problem-solving skills of student radiographers, there is a need for curriculum adjustment to nurture and encourage this competency. Conclusion. Facilitators need to be taught methods to integrate problem solving into the curriculum, and learning material must be adjusted to accommodate problem solving for this skill to become part of the programme outcomes. AJHPE 2014;6(1):33-36. DOI:10.7196/AJHPE.297

Currently, radiography students are faced with the challenge of having to learn factual information, while being taught how to interpret the information available to them to problem solve and reflect on their judgement within a given clinical context.[1,2] Problem solving is a vital competency for healthcare professionals in an era of rapidly advancing technology.[3,4] It requires critical thinking, and improves the quality of a clinical service offered and the efficiency of delivering such a service.[5] Therefore, enabling students to problem solve will in turn improve clinical competence.[4] To improve problem-solving skills of radiographers, problem-based learning (PBL) has been incorporated in the radiography curriculum in certain institutions in Africa, one of which is the Makerere University in Uganda. PBL was first introduced into medical education in the 1960s in Ontario, Canada for physicians.[2] It is a popular teaching method, utilising problem-solving skills, and has been used successfully for some radiography, nursing and paramedic curricula.[6,7] However, a gap still exists in the literature on the assessment of problem-solving abilities in radiography. The skill can be defined as the studentâ&#x20AC;&#x2122;s ability to use objectives and operations to reach a specific goal within certain constraints.[8] It requires inference, involving the identification of factors to come to reasonable conclusions.[3,9] A student who demonstrates good problem-solving skills considers relevant information to deduce judgements, inferences, statements, beliefs and opinions. This competency encompasses the ability to query evidence, present alternatives and draw conclusions.[9] Freeman and Lewis[8] highlight four components of problem solving, i.e. goal (the solution), objects (what can be used to reach the goal), operations (permitted actions in reaching the goal) and constraints (limitations). In

addition, they identify the concept of well-defined problems (all necessary information is given) and ill-defined problems (little or no information is given). In the health sciences, most problems fall into the latter category.[8] The competency requires critical thinking, which causes individuals to constantly improve their skills for personal and professional growth, thus enabling healthcare workers to make more informed decisions in the clinical environment.[4,10] Therefore, teaching students to problem solve allows the practitioner to integrate theory and practice, improves clinical reasoning and addresses the needs of the patient owing to clinical efficiency and better patient care.[4,5,10] The South African Qualifications Authority (SAQA) added a new dimension to teaching, learning and assessment with the publication of the critical cross-field outcomes that students need to attain in addition to the programme outcomes. Critical thinking and problem solving are listed among the 12 outcomes. Although the publication dates back to 1995, it is valid to question the ability of third-year radiography students to attain these specific outcomes, as information in this field in a radiography context is lacking.[11] In the South African context, problem-solving skills among radiography students have not been assessed. The ability of the students to demonstrate problemsolving skills needed to be explored so that the Department of Radiography could develop a more explicit curriculum to facilitate these competencies. The aim of this study was to evaluate the problem-solving skills of thirdyear radiography students at a comprehensive South African university.

Methods

A descriptive exploratory research design was used to collect both quantitative and qualitative data. The study design was selected to explore,

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Research identify and describe themes and patterns in the data, which were then used to judge the students’ problem-solving skills.[12] Students were asked to pose a solution to a scenario-based vignette, constructed by the researcher, and tailor made for radiography students to extract problem-solving skills in a radiography context. The participants’ skills were then assessed using a rubric designed by the researcher (Appendix 1) after a literature review to obtain information on current and popular data collection tools used in the assessment of this competency in higher education. The rubric consisted of a list of attributes integral to problem solving, supported by concepts found in the literature. These included understanding of the problem, planning of an appropriate solution, ability to carry out the plan correctly and logically, and ability to evaluate the result.[3] Each vignette was assessed by assigning a score from 1 (not at all) to 4 (to a large extent), and this information was used to generate the quantitative data. In addition, the researcher wrote extensive field notes, indicating the thought processes of the participants for each attribute identified as integral to problem solving. By reading participants’ responses to each vignette, as advocated by Creswell,[13] the researcher reflected on the data, reread the participants’ responses and assigned a value according to the Likert scale as well as attributes identified for each vignette. In addition, the researcher made notes inductively on the thought processes relating to the participants’ responses to the specific vignette, thus generating qualitative data. The quantitative data were therefore further supported by the qualitative data. The vignette designed to extract the critical thinking skills of problem solving used in this study was as follows: ‘A 36-year-old female patient presents to the imaging department with a 5-day history of numbness and pins and needles in her right arm. The patient is 8 weeks’ pregnant. The referring physician has requested a radiograph of the lumbar spine. Apply your knowledge to the above scenario and hypothesise what you would do in the above situation.’ The attributes integral to problem solving were then assessed. The cohort for this research study consisted of third-year radiography students (N=73) at a South African university. A single-stage sampling design was used as a sampling frame, which could be developed from the number of students registered. Furthermore, a non-probability sampling approach was used for convenience, the researcher’s access to the third-year radiography students and their availability. The study sample consisted of 59% (n=43) of the total cohort of registered students. Ethical clearance was given by the Ethics Committee of the Faculty of Health Sciences of the university concerned. Permission to conduct the study was obtained by the Head of the Department of Radiography at the university where the study was conducted. Participants were recruited once informed consent was obtained and confidentiality was ensured by assigning numbers to participants. The researcher gave the problem-solving vignette to the students, who were instructed to respond in writing. Participants were reminded of their voluntary participation, and responses to the problem-solving vignette were collected by the class representative and handed back to the researcher. The vignette was handed to the participants once the researcher was assured that they had gained the theoretical knowledge and had attended the practical demonstration relating to the topics of the problem-solving vignette. To ensure that participants did not discuss their answers, the vignettes were handed out in an assessment environment, in the presence of an invigilator.

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On completion of the vignette, the researcher assessed the problemsolving skills of participants using the 4-point Likert scale according to the attributes identified for problem-solving skills. Detailed field notes of each participant’s response to the vignette were compiled. To ensure the validity of the vignettes, a field expert was consulted to verify the suitability of questions used prior to data collection. The selfdesigned measurement rubrics used in this study were also verified by a field expert. This ensured that the use and measurement of the problemsolving vignette were appropriate and applicable to problem-solving skills, and based on the theoretical and practical knowledge that the student had gained to answer the vignette. In addition, triangulation of data by statistical analysis and the generation of themes,[13] as well as the use of an independent coder, further ensured validity of the research process. Reliability was ensured through consultation with an independent coder to review students’ responses to vignettes, only after the researcher had reviewed and documented the responses. By comparing results with the independent coder, consensus was achieved regarding the rating for a particular student’s response, thereby avoiding any bias from the researcher. Observation of 10 subjects or events by an independent coder is considered adequate judgement to ensure inter-rater reliability, as advocated by Burns and Grove.[12] Another indication of the reliability of a measurement tool is its internal consistency.[14] Statistical analysis of Cronbach’s coefficient alpha was performed for problem-solving skills measured in this study, its value achieved being 0.924 with four items on the scale. Dependability was ensured by triangulating data collection, as well as by providing a dense description of the research methods.[15] The numerical data were analysed statistically using SPSS. The qualitative data were analysed as suggested by Creswell,[13,16] by coding the information, generating themes from the codes and interpreting the meaning of the data. This was achieved by reading the participants’ responses to each vignette, reflecting on the data and re-reading the responses. This method enabled the researcher to make in-depth field notes inductively while assigning a value (according to the 4-point Likert scale) for each of the attributes identified to rate the participants’ responses to the vignette. The field notes were then coded, forming themes, and verbatim quotes were added as supportive evidence.

Results

Measurement of problem-solving skills was subdivided into four attributes (understood the problem, planned an appropriate solution, carried out the plan correctly and logically, and evaluated the result) considered integral for demonstrating problem solving. The attributes were scored on a 4-point Likert scale. The mean score for the participants’ ability to demonstrate problem-solving skills was 2.32, indicating a minimal ability to problem solve. Of the 43 participants, 20.4% could problem solve to a large extent, while 29.7% showed no problem-solving skills. It is interesting to note that 46.5% of participants understood the problem, 14% planned an appropriate solution and 11.6% carried out the plan correctly and logically.

Quantitative data

Fig. 1 illustrates the ability of participants to demonstrate the attributes of problem-solving skills. Almost half of the group understood the problem, while the majority were unable to plan a solution and carry out an

Research

Minimally

Moderately

To a large extent

44.2

46.5

Not at all

32.6

30.2

9.3

11.6

Discussion

23.3

30.2 14

20.9

34.9

30.2

30 16.3

Participants, %

34.9

45 35

if the pins are still aligned . . .’ – participant 35. ‘Pins and needles down the arm would be an indication a cervical examination not lumbar. The patient being pregnant will also limit the amount of views . . .’ – participant 49.

5 0 Understood the problem

Planned an appropriate solution

Carried out the plan correctly

Evaluated the result

Critical-thinking attributes

Fig. 1. Participants demonstrating attributes of problem-solving skills.

Table 1. Ability of participants to demonstrate attributes of problem-solving skills (N=43) Attributes for critical thinking skills: problem solving

Mean score (maximum = 4)

Standard deviation (SD)

Understood the problem

2.84

±1.194

Planned an appropriate solution

2.23

±1.088

Carried out the plan correctly and logically

2.19

±1.052

Evaluated the result

2.00

±0.926

Total mean

2.32

±1.065

appropriate plan. Just over 40% of participants in this vignette were able to evaluate the result to a minimal level. Table 1 indicates the mean score for the attributes demonstrating problem-solving skills. The standard deviation (±SD) ranges from 0.926 to 1.194. Looking at this large variation in SD, and with reference to Fig. 1, one can observe that although the total mean score for participants to demonstrate problem-solving skills was minimal, some participants achieved a moderate score and others a ‘not at all’ score, proving a greater degree of variability for this skill.

Qualitative data

The quantitative data are further supported by the results of the qualitative data. The vignette called for each participant to demonstrate problem-solving skills by determining that the examination requested did not correlate with the clinical symptoms and providing a possible course

of action. Compounding the problem was the fact that the patient was 8 weeks’ pregnant. The participants’ answers to the vignette led to the generation of the following theme: ‘Inability to analyze the problem’. The researcher concluded that participants have the ability to identify problems that may exist in the vignette, but are unable to identify solutions, or they propose solutions that are not feasible in the given scenario. The following verbatim quotes were extracted from the participants’ vignettes to support this theme: ‘I would suggest that the patient has an MRI of the lumbar spine . . .’ – participant 42. ‘First I would advise her to go to another physician for second opinion, if she is willing I would do AP, lateral and oblique views for the lumbar spine, and a AP pelvis . . .’ – participant 29. ‘Considering that I will never do the lumbar spine I will do only the right arm lateral to see

Participants in this study very clearly understood the problem by highlighting the obvious (that the patient was 8 weeks’ pregnant), but then neglected to notice that the patient’s history did not correlate with the requested radiographic examination. As participants were unable to reflect on the vignette as a whole, their problem-solving ability was limited, with many unable to link the clinical information given and the examination requested – therefore not recognising the problem. Participants who correctly identified the mismatch between the clinical information given and the examination requested were not sure of the correct procedure to follow. This led to some participants being unable to suggest a reasonable solution to the problem and some resorted to refusing to X-ray the patient. A study by Fero et al.[17] on nursing students’ critical-thinking skills yielded similar results to those found in the current investigation, revealing that 75% of student nurses did not meet overall expectations relating to a given simulation designed to test for problem-solving ability. Most nursing student errors were associated with problem recognition and reporting findings to the referring doctor. Almost half of the participants in Fero’s et al.'s study correctly recognised the problem, while 100% were unable to justify their decisions.[17] In the current study, participants realised that they should not take a radiograph of a pregnant patient, but seemed unable to design an appropriate path to follow. Again, when faced with a problem to solve, participants tended to refer the matter to a qualified radiographer who would instruct them with regard to a course of action, or take over the patient from them, thereby eliminating the student from the problem-solving process. This minimal ability to problem solve could be due to students not being given the opportunity to think for themselves. In busy imaging departments, students tend to step aside when complications arise, and allow the qualified radiographer to take the lead. Very often students

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Research might continue with another patient, instead of following through with the initial patient and assisting the qualified radiographer. The findings of this study are unique to the radiography setting and provide a platform for further studies in problem solving in radiography education. A literature survey revealed that problem-solving skills can be taught to students using various methods that should be integrated into the curriculum. However, before educators can expect students to demonstrate problemsolving skills, facilitation of these skills must be incorporated into the academic programmes.[3,5,18]

Conclusion

The results of this investigation demonstrate that the majority of radiography students who participated in this study were unable to problem solve to a large extent in a written clinical scenario, and therefore the current students will not have the ability to optimally apply these skills in a clinical setting. Regretfully, this study has revealed that radiography educators at the university concerned have not adequately facilitated the development of problem-solving skills among third-year radiography students. Therefore, interventions are required to meet the standards stipulated by SAQA. Implementation of role-play, video-taped simulation sessions, use of case studies, as well as integrated assessments are modalities that should be included in the curriculum to encourage and nurture problem-solving skills and in turn improve clinical efficiency of student radiographers.

Acknowledgement. We acknowledge the staff qualification project of the University of Johannesburg. References 1. Spencer C. Critical thinking in nursing: Teaching to diverse groups. Teaching and Learning in Nursing 2008;3:87-89. 2. Kowalczyk N, Leggett TD. Teaching critical-thinking skills through group-based learning. Radiologic Technology 2005;77(1):24-29. 3. Castle A. Defining and assessing critical thinking skills for student radiographers. Radiography 2009;15:70-76. 4. Distler JW. Critical thinking and clinical competence: Results of the implementation of student centered teaching strategies in an advanced practice nurse curriculum. Nurse Education in Practice 2007;7(1):53-59. 5. Agwu KK, Ogbu SOI, Okpara E. Evaluation of critical thinking application in medical ultrasound practice among sonographers in south-eastern Nigeria. Radiography 2007;13:276-282. 6. Edwards H. Critical thinking and the role of the clinical ultrasound tutor. Radiography 2006;12(3):209-214. 7. Kiguli-Malwadde E, Francis B, Gonzaga MA. Attitudes and perceptions of students and teachers about problem based learning in the radiography curriculum at Makerere University, Uganda. European Journal of Radiography 2009;1:156-162. 8. Freeman R, Lewis R. Planning and Implementing Assessment. London: Kogan Page, 1998:236. 9. Facione PA. Critical thinking: What it is and Why it Counts. Millbrae: Measured Reasons and the California Academic Press, 2011. http//www.insightassessments.com (accessed 22 August 2011). 10. Popil I. Promotion of critical thinking by using case studies as teaching method. Nurse Education Today 2011;31:204-207. 11. South African Qualifications Authority. Qualifications and Unit Standards, Qualification ID number 66949. http://www.saqa.org.za (accessed 23 March 2010). 12. Burns N, Grove SK. The Practice of Nursing Research: Conduct, Critique and Utilization. 5th ed. St Louis: Elsevier, 2005:232. 13. Creswell J. Research Design: Quantitative, Qualitative and Mixed Methods Approaches. 2nd ed. London: Sage, 2003:190-195. 14. Pallant J. SPSS Survival Manual. 3rd ed. Glasgow: Bell and Bain, 2007:6. 15. De Vos AS. Research at Grass Roots: For the Social Sciences and Human Services Professions. 4th ed. Pretoria: Van Schaik, 2011:443-444. 16. Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 3rd ed. Los Angeles: Sage, 2013:186-188. 17. Fero LJ, O’Donnell JM, Zullo TG, et al. Critical thinking skills in nursing students: Comparison of simulationbased performance with metrics. Journal of Advanced Nursing 2010;66(10):2182-2193. 18. Castle A. Assessment of the critical thinking skills of student radiographers. Radiography 2006;12:88-95. 19. Kiah CJ. A model for assessing critical thinking skills. Conference Proceedings: Annual Student Assessment Conference of the Virginia Assessment Group and the State Council of Higher Education for Virginia, 1993.

Appendix 1. Problem-solving rubric[8,19] 1 = not at all • Understood the problem (interpretation, identifies essentials of the goal to be achieved) • Planned an appropriate solution (generation, addresses core issues, uses a feasible plan, plan is reasonable for achieving goal) • Carried out the plan correctly and logically (strategising, steps in achieving the goal are clearly set out) • Evaluated the result (reflection, strengths and weaknesses identified)

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2 = minimally

3 = moderately

4 = to a large extent

Research Introduction of a learning management system at the Kilimanjaro Christian Medical University College L Killewo,1 BA; E Lisasi,1 MD, MPH; G Kapanda,1 MSc; D Tibyampansha,1 BS; G Ibrahim,1 BA, MPH; A Kulanga,1 MBA; C Muiruri,2,3 MPH; N Fadhili,1 MCA; D Wiener,2,5 AS; A Wood,5 BA; E Kessi,1 MD, MMed, MSc; K Mteta,1,4 MD, MMed; M Ntabaye,4 DDS, PhD; J A Bartlett,1-3 MD 1

Kilimanjaro Christian Medical University College, Moshi, Tanzania

Duke University School of Medicine, Durham, North Carolina, USA

Duke Global Health Institute, Durham, North Carolina, USA

Kilimanjaro Christian Medical Centre, Moshi, Tanzania

Learning Content Management System, Durham, North Carolina, USA

Corresponding author: L Killewo (amlucy2000@yahoo.com)

Background. Medical schools in Africa face daunting challenges including faculty shortages, growing class sizes, and inadequate resources. Learning management systems (LMS) may be powerful tools for organising and presenting curricular learning materials, with the potential for monitoring and evaluation functions. Objective. To introduce a LMS for the first-year medical student curriculum at the Kilimanjaro Christian Medical University College (KCMU Co), in Moshi, Tanzania, in partnership with the Duke University School of Medicine (Durham, North Carolina, USA). Methods. Observations were made on the requisite information technology (IT) infrastructure and human resource needs, and participation in training exercises. LMS utilisation was recorded, and two (student and faculty) surveys were done. Results. The KCMU Co IT infrastructure was upgraded, and an expert team trained for LMS implementation. An introductory LMS workshop for faculty had 7 out of 25 invitees, but attendance improved to more than 50% in subsequent workshops. Student attendance at workshops was mandatory. Use of the LMS by students rapidly expanded, and growing faculty utilisation followed later. By the end of the second semester, online examinations were offered, resulting in greater student and faculty satisfaction owing to rapid availability of results. A year after LMS introduction, 90% of students were accessing the LMS at least 4 days/week. A student survey identified high levels of satisfaction with the LMS software, quality of content, and learning enhancement. Conclusion. LMS can be a useful and efficient tool for curriculum organisation, administration of online examinations, and continuous monitoring. The lessons learned from KCMU Co may be useful for similar academic settings. AJHPE 2014;6(1):37-40. DOI:10.7196/AJHPE.260

Sub-Saharan Africa faces an extraordinary burden of human disease, with a dire shortage of healthcare providers to address this burden.[1] The training of medical doctors is essential, but current training capacity falls far short of meeting anticipated needs. About 167 000 new doctors will be needed in sub-Saharan Africa by the year 2015, but only 30 000 are expected to graduate in this period.[1] Ministries of Health and Education, and the private sector, have responded by opening many new medical schools across the continent, and mandating that each school rapidly expand its class size.[1] Despite these efforts, the delivery of medical education in sub-Saharan Africa faces great challenges, including poor infrastructure, inadequate number of medical schools, insufficient number of faculty members, poor compensation for faculty and graduates, and a continued increase in student enrolment without a commensurate increase in faculty numbers and infrastructure to accommodate the changes.[1] Creative interventions to overcome these challenges are sorely needed, including the use of modern technologies and teaching methods that optimise medical student learning, despite limited resources. One approach to enhance efficiency and organisation is the use of a learning management system (LMS). LMS has been defined as ‘a software application or web-based technology that is used to plan, deliver or access a

particular learning process’.[2] In upper- and middle-income countries, LMSs are extensively used in universities and businesses for organising and sharing learning materials, communications, and evaluating students/learners. In a survey of 25 African countries, 4 major impediments to successful utilisation of LMSs were identified:[2] (i) knowledge of LMS was limited, with only 49% responding that they had used a LMS for teaching and 52% for learning in the previous 12 months. Furthermore, they had limited knowledge of the broad capabilities of a LMS, with only approximately 50% of respondents demonstrating knowledge of 18 specific LMS features; (ii) infrastructure shortcomings in internet bandwidth and steady electricity supply were major impediments to usage. This was supported by a study of computers, the internet and medical education in Africa which revealed that internet speeds were rated as ‘slow’ or ‘very slow’ by 25% of respondents, with the percentage rising to 58% in East Africa.[3] In addition, the ratio of computers to students was 1:0.123;[3] (iii) training in the use of LMS was limited, and 25% of respondents indicated a history of less than 2 hours of training in LMS use; and (iv) a lack of shared content and open educational resources within Africa. A recent survey of medical schools in resource-constrained low- and middle-income countries revealed that a limited number in sub-Saharan Africa were employing a LMS for the management of their curriculum and students, and none had systematically examined their impact.[4]

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Research

160 140 120 100 80 60 40 20

Admission year Fig. 1. Growth in KCMU College medical school admissions from 1997 to 2011. Acquisition of LCMS+

July 2011

System set-up, configuration and testing (Duke system development and KCMU Co staff co-ordinating activities closely) System content familiarisation and customisation System work plan and usage

Sept 2011

Introduction of LCMS+ Communicated with potential users Call for course materials submission Development of security and user privileges Uploading course materials First training to faculty members

Nov 2011

Official launching System introduction and training for students Continuous system support, training and usage monitoring

Preparation for online examinations

Jan 2012

Training for faculty, staff and students Receiving and uploading examinations to the system

Online examination administration

Feb 2012

Preparing computers, computer rooms and invigilators Examination administration Feedback from faculty and student surveys

Fig. 2. LCMS+ implementation timeline.

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2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

0 1999

KCMU Co is located in Moshi, Tanzania, and is one of 6 Tanzanian medical schools. It is overseen by the Good Samaritan Foundation, and has 3 faculties offering 16 different health-related degrees. Its principal clinical training site is the Kilimanjaro Christian Medical Centre (KCMC), one of 4 referral hospitals in Tanzania serving an estimated population of 16 million. Similarly to many other sub-Saharan medical schools, KCMU Co has rapidly expanded its class sizes in the past 10 years. Fig. 1 shows the dramatic increase in the numbers of admitted students from 1997 - 2011. Unfortunately, the increase in the number of admitted students has not been accompanied by increases in faculty size or other key infrastructure components. As a result, faculty are overwhelmed and teaching obligations decrease in priority. In an informal survey conducted at KCMU Co in 2010, faculty delivered less than 40% of their scheduled lectures to students. As a result, students were forced to pursue self-directed and group learning, frequently without faculty guidance or teaching. The MEPI Leadership Team visited the Duke University School of Medicine (Durham, North Carolina, USA) to evaluate different options for an LMS intervention, including proprietary and open-source software. Important considerations were a proven record of successful hosting of medical school curricula, ease of use by students and faculty, availability of programming support, ability to deliver online examinations, monitoring and evaluation functions, and ability to easily track system activities and usage. The LMS chosen for intervention was developed by the Duke University School of Medicine, a key KCMU Co partner. It was developed specifically for medical education at Duke, and is known as the Learning

Empowered by the KCMU Co and KCMC leadership, a team was developed to support the LMS intervention, led by an LMS specialist with

1998

Setting

LMS team development

1997

Methods

a background in information technology (IT) and some experience in managing educational applications. She travelled to Duke for training, and had weekly conference calls with the LCMS+ developers. In addition, the LCMS+ developer travelled to KCMU Co to assist with on-site training. She was supported by three IT specialists who oversaw the development of a fibre optic cable network on campus and internet and intranet

and Curriculum Management System+ (LCMS+). LCMS+ is now manufactured, marketed and maintained by LCMS+ Inc., Durham, North Carolina, USA.

Number of admitted students

Similar to other medical schools in sub-Saharan Africa, the Kilimanjaro Christian Medical University College (KCMU Co) in Moshi, Tanzania, has experienced rapid growth in medical student class size, increasing from 15 when it opened in 1997 to 154 in 2011. In 2010, KCMU Co received funding from the United States Government through the Medical Education Partnership Initiative (MEPI),[5] a programme designed to assist sub-Saharan Africa by increasing the number and quality of physicians, to increase their retention in underserved areas, and to improve research capacity. With this support, KCMU Co introduced an LMS in October 2011 to manage the first-year curriculum and the incoming first-year students.

Research Editorial services. The timeline for the development of the LCMS+ team and initial implementation is shown in Fig. 2.

Training of KCMU Co faculty, students and staff

Once the LCMS+ was installed and ready for use, the KCMU Co Dean informed faculty about its planned introduction. A carefully organised introductory training workshop was held in September - November 2011 for KCMU Co faculty, students and staff, followed by an online examination workshop in January 2012. On-demand training and ongoing support services continued to be offered at individual to departmental levels. It was decided to initiate LCMS+ implementation with the first-year medical students entering in October 2011, and in subsequent years the LCMS+ would be extended by one class each year.

Survey assessments

Surveys were developed to assess faculty and student feedback on the LCMS+. All surveys were conducted anonymously online. Faculty and students were surveyed in February - March 2012 to solicit feedback following the introduction of online examinations. Students completed a survey on LCMS+ in December 2012, following completion of the first semester in their second year. Our LCMS+ survey adapted DeLone and McLean’s[6] updated information systems success model as a way to explicitly measure and assess success. We chose this model because of its success metrics, which are specifically designed for the e-learning context. The LCMS+ student survey consisted of 15 questions using a 5-point Likert scale for responses (1 = strongly disagree to 5 = strongly agree), and focused on the quality of the software, quality of content, learning enhancement, complaints, and preferences for future content. Mean scores were calculated for student responses, and strength of consensus measure (sCns) was applied to test for response consistency.

online examinations in a week or less; the remaining 2 needed 2 weeks. Six faculty members reported that previously they had needed more than 2 weeks to grade ‘paper’ exams, whilst online examinations were graded instantaneously. All faculty members answered that they had a positive experience with online examinations, and 100% indicated that they planned to continue to use them in future. Of 116 students responding to the survey, 88% preferred online to paper examinations. Most (72%) students stated that they preferred online examinations because of the short turnaround time to receive feedback on their examination grades. Most (85%) felt that the multiple choice questions were clearly written, although only 20% of students felt that enough time had been allocated to answer each question.

Table 1. Informal survey of faculty attitudes – first workshop Percentage of faculty (n=7)

Attitude

Fear of change and adapting to the new system

Did not believe that the system could work in an African setting, particularly at KCMU Co

Eager to learn and see how the system was going to change and improve the culture of teaching and learning

Table 2. LCMS+ student survey mean scores and consensus measures Mean scores

Consensus measure, %

Quality of software

3.93

User friendly

4.3

Stability

3.7

Security

4.0

Interactivity

3.7

Quality of content

4.19

Well organised

4.2

Effectively presented

4.0

Appropriate length

4.0

Clearly written

4.3

Use for learning

4.5

Up-to-date

4.2

Clear course objectives

4.1

Appropriate terminology

4.2

Utilisation rapidly increased during the first months of LCMS+ availability. By January 2012, after 3 months of LCMS+ activity, 220 students (including medical and master’s students) and 34 faculty had accessed the system. In December 2012, a year after implementing LCMS+, a survey of 2nd-year medical students revealed that 90% of them were accessing the LCMS+ at least 4 days/week, and 57% were accessing it 6 - 7 days/week.

Used effectively

4.2

Learning enhancement

4.2

Stronger analytical skills

4.3

Faster learning

4.3

Better individual learning

4.3

Less dependent on library

4.1

Online examinations

Flexible study schedule

4.3

Better communication

3.9

Ethical clearance

All research related to the MEPI was reviewed by the KCMC Research Ethics Committee, and was exempted from a full review because of its focus on education. Participation in the study assessments by faculty, staff and students was preceded by verbal consent. All survey results were anonymous.

Results

Workshop participation

At the first workshop to introduce faculty and staff to LCMS+, only 7 out of 25 invited members attended. An informal survey of faculty revealed the expectations summarised in Table 1. A second workshop was offered in late January 2012, near the start of the second semester, and 42/60 invited faculty and staff attended. Workshops for students were held in October 2011 and January 2012, and participation was mandatory; 154 students attended each workshop.

LCMS+ utilisation

Eight faculty and 116 students responded to the online examinations survey. Six faculty members (75%) reported that they were able to prepare

Category

May 2014, Vol. 6, No. 1 AJHPE

Editorial Research Student surveys

A total of 154 2nd-year medical students participated in the student surveys on LCMS+, representing the entire class that had utilised LCMS+ since entering medical school in October 2011. The mean scores by category and consensus measures are in Table 2. Overall, the mean scores ranged from 3.7 - 4.5, with a consensus measure of 73 - 91%. In the category of quality of software, the mean scores were 3.7 - 4.3 with consensus measures of 73 - 85%. In the category of quality of content, the mean scores ranged from 4.0 - 4.5, with consensus measures of 81 - 91%. In the category of learning enhancement, the mean scores ranged from 3.9 - 4.3, with consensus measures of 77 - 87%. Complaints about LCMS+ were also solicited; the most common were late posting of materials (25%), difficulty in submitting assignments (21%), student misuse of bulletin boards (16%), downloading and printing of documents (14%), and difficulty contacting lecturers (11%). Preferences for future content and services expressed by at least 50% of students included access to online libraries (86%), access to previous tests and answers (79%), e-mail notification of announcements (67%), access to previous study materials (60%), and discussion groups/wikis (52%).

Discussion

The introduction of LCMS+ at KCMU Co has proven successful, with rapid utilisation by students and faculty, online testing with strong preferences in favour of this method from students and faculty, and highly favourable student surveys supporting the use of LCMS+, with a high degree of consensus. Compared with paper examinations, online examinations have reduced paper usage, and printing and labour costs. In addition, faculty time spent on script marking and producing examination report was greatly reduced, and students appreciated the rapid turnaround of examination grade feedback. The original intent in introducing LCMS+ at KCMU Co was to focus on implementation exclusively with medical students, progressing from the first-year class in 2011 and adding one new medical student class per year. However, the demand for LCMS+ access spread rapidly within the college, and LCMS+ is now used to support the curricula of 3 medical school classes and 3 master’s in medicine programmes. Two new staff specialists have been hired to address the increased demand for LCMS+ services. Taken together, these observations suggest outstanding value for LCMS+ in organising, presenting and testing curricular content. Three of the top 5 complaints about LCMS+ relate to late postings, student misuse of bulletin boards, and difficulty contacting lecturers − issues that relate to users and not to the system itself. The LCMS+ has the capacity to evolve with time, and will in the future respond to KCMU Co student requests for the addition of materials such as online libraries, previous study materials and tests, and discussion groups. The published experience of other sub-Saharan African schools of medicine is limited, and does not include similar assessments of user satisfaction.[4] The University of KwaZulu-Natal described 6 academic programmes using Moodle as an LMS, largely within their School of Nursing.[7] They identified computer access as an obstacle to implementation, with difficult access during working hours and a lack of personal computer access outside working hours. The University of Colombo in Sri Lanka described their experience with using Moodle as an LMS beginning in 2007, and performed a random survey of 100 medical students[7] of whom 99% responded that the LMS material was useful, and faculty enthusiasm was described as ‘high’.[8] The use of LCMS+ by KCMU Co offered important advantages for implementation. It was specifically designed to host medical school curricula, and most of the programming development was complete

May 2014, Vol. 6, No. 1 AJHPE

prior to its adoption at KCMU Co. Technical support has been provided gratis by the Duke University School of Medicine and LCMS+, Inc., in recognition of the long-standing 17-year partnership between KCMU Co and Duke. Other sub-Saharan African schools of medicine may find the cost of this proprietary software to be an obstacle, and may wish to utilise open-source software such as Moodle. They should be aware of the programming support needs if they elect to pursue the option of Moodle or other open-source software. The use of electronic aids in medical education may have significant impact, especially in low- and middle-income countries where faculty shortages are common. However, when they are introduced, careful planning and preparation is essential. Frehywot et al.[4] identified 4 critical strategies for ensuring the success of e-learning interventions: institutional support, technical expertise in IT, adequate infrastructure and support systems, and faculty and student engagement. The experience of KCMU Co in LCMS+ implementation underscores the importance of these factors. There are a number of limitations to these observations. Firstly, we have described implementation, rapid uptake and utilisation, and highly favourable subjective responses to the introduction of LCMS+. However, we do not have objective evidence of improved medical student performance. Secondly, we had the unique opportunity to invest in educational infrastructure with MEPI support, and to access LCMS+ from Duke University at no cost. Thirdly, we do not have any comparative data on the use of other LMSs in medical education within resource-limited settings. Lastly, the survey instruments used were internally developed and had not undergone validation. There were some challenges caused by system users: late posting of materials, student misuse of bulletin boards, and difficulty contacting lecturers. We have found that users were lacking knowledge on how to efficiently and effectively use the system. These issues have been addressed. Provision of education to users can help to solve these problems.

Conclusion

The introduction of LCMS+ at KCMU Co has assisted with curricular organisation, presentation and testing. It has been rapidly adopted by the students and faculty with very favourable responses. Other schools of medicine in sub-Saharan Africa may wish to implement similar efforts. Conflict of interest. This study was supported by the Medical Education Partnership Initiative and Health Resources and Services Administration award T84HA21123. DW and AW are employees of LCMS+, Inc.; JAB and CM are employees of Duke University, which has a financial interest in LCMS+, Inc. The authors of this article have no conflict of interest to report. References

1. Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011;377(9771):1113-1121. [http://dx.doi.org/10.1016/S0140-6736(10)61961-7] 2. Unwin T, Kleessen B, Hollow D, et al. Digital learning management systems in Africa: Myths and realities. Open Learning 2010;25(1):5-23. [http://dx.doi.org/10.1080/02680510903482033] 3. Williams CD, Pitchforth EL, O’Callaghan C. Computers, the internet and medical education in Africa. Med Educ 2010;44(5):485-488. [http://dx.doi.org/10.1111/j.1365-2923.2009.03602.x] 4. Frehywot S, Vovides Y, Talib Z, et al. E-learning in medical education in resource constrained low- and middleincome countries. Hum Resour Health 2013;11:4. [http://dx.doi.org/10.1186/1478-4491-11-4] 5. Medical Education Partnership Initiative. Fostering African Medical Education Community of Excellence, 2011. http://mepinetwork.org/about-mepi/coordinating-center.html (accessed 28 February 2013). 6. Holsapple CW, Lee-Post A. Defining, assessing and promoting e-Learning success: An information systems perspective. Decision Sciences Journal of Innovative Education 2006;4(1):67-85. [http://dx.doi.org/10.1111/ j.1540-4609.2006.00102.x] 7. Mars M. Building the capacity to build capacity in e-health in sub-Saharan Africa: The KwaZulu-Natal Experience. Telemed J E Health 2012;18(1):32-37. [http://dx.doi.org/10.1089/tmj.2011.0146] 8. Rajapakse S, Fernando D, Rubasinghe N, Gurusinghe S. e-Learning in medical education: Guide supplement 32.6 − Practical application. Med Teach 2009;31(5):452-453. [http://dx.doi.org/10.1080/01421590902833036]

Research Medical and dental students’ willingness to administer treatments and procedures for patients living with AIDS A Y Oyeyemi,1 DHSc; U S Jasper,2 BMR; A Oyeyemi,3 PhD; S U Aliyu,4 MEd; H O Olasoji,5 BDS; H Yusuph,6 MBBS 1

Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria and Dominican College Program in Physical Therapy, Orangeburg, New York, USA

Department of Medical Rehabilitation (Physiotherapy), University of Maiduguri, Maiduguri, Borno State, Nigeria

Department of Physiotherapy, University of Jos Teaching Hospital, Jos, Plateau State, Nigeria

Department of Physiotherapy, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria

Department of Oral and Maxillofacial Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria

Department of Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria

Corresponding author: U S Jasper (jaspersnd64@gmail.com)

Background. Nearly three decades after the discovery of the human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) epidemics continue to pose significant challenges to low-income countries in sub-Saharan Africa. Objective. To assess medical and dental students’ willingness to perform specific techniques and procedures on people living with AIDS (PLWA). Methods. A survey was done among medical and dental students (N=304) at a Nigerian University using a 21-item questionnaire that elicited responses on sociodemographic characteristics and willingness to perform specific techniques and procedures. Analysis of variance (ANOVA) and an independent t-test were used to determine the influence of sociodemographic variables. Multiple regression analyses were used to determine the predictors of willingness. Results. The cohort of medical and dental students was willing to care for PLWA. Almost all medical students were either undecided or unwilling to perform mouth-to-mouth resuscitation. A higher proportion of dental students were either undecided or unwilling to assist during surgery, tooth extractions and other procedures they considered to be invasive. More medical than dental students were willing to carry out surgical procedures. Previous personal encounters with AIDS patients, religion, and satisfaction with instructions influenced medical and dental students’ willingness to care for PLWA, while knowing a family member living with AIDS (R2=0.22, p<0.001) was the strongest predictor of willingness to care for PLWA. Conclusion. Extensive use of clinical clerkships and exposure through direct experience are viable strategies necessary for optimising and enhancing medical and dental students’ dispositions to perform procedures and care for PLWA. AJHPE 2014;6(1):41-44. DOI:10.7196/AJHPE.201

Nearly three decades after the discovery of the human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) epidemics continue to pose significant challenges to low-income countries in sub-Saharan Africa and to impact on the attrition rate, level of motivation, professional practices and absenteeism from work of healthcare workers. [1] About 90% of HIV infections among healthcare workers occur in developing countries, where occupational safety procedures are often neglected.[2] While a cure and an effective vaccine have not been found for AIDS, many people living with HIV/AIDS in Nigeria are still being denied access to treatment.[3-5] It is a generally believed that, given the widespread stigmatisation of HIV/AIDS patients, even among healthcare workers, including doctors and dentists,[6,7] the behaviour towards people living with AIDS (PLWA) continues to play a vital role in care and treatment. Fear of contagion, concerns for safety, poor attitude and unwillingness to provide care to PLWA among healthcare personnel and students remain widespread.[7,8] Consequently, students’ knowledge and the attitude of healthcare professionals and students towards PLWA continue to be of interest. Healthcare workers’ attitude remains a core reason why many Nigerians living with HIV/AIDS are denied access to treatment.[5,9-12]

A previous study has shown that medical students in the USA believed that their education had not prepared them to safely treat PLWA,[8] and Taiwanese dental students were found to be more willing to treat hepatitis B virus (HBV)- and hepatitis C virus (HCV)-infected patients than those with HIV infection.[13] Recently, Sudanese dental students felt that they were not well prepared for their future task of treating patients with HIV/AIDS.[14] Another study showed that on average 60% of Nigerian dental students were willing to care for PLWA.[5,9] A widespread poor attitude and disposition among students may continue after completion of their studies. The goal of any professional education is to produce practitioners with competencies in the technical and non-technical aspects of practice. Technical competence is the ability to perform a specific task in a given situation, while non-technical competence involves the nuances and understanding that enable a practitioner to communicate effectively with patients and other healthcare professionals and select appropriate treatment and procedures.[15] Therefore, a preferred professional programme should prepare students with the necessary cognitive, psychomotor and affective skills, including a positive disposition to provide care and perform procedures on patients with any condition, including transmissible diseases such as AIDS. It has been shown that a willingness to treat patients with HIV/AIDS may be related to knowledge of the disease process, recognition of its

May 2014, Vol. 6, No. 1 AJHPE

Research manifestations, and understanding of its modes of transmission. [16] However, knowledge alone may not be sufficient to guarantee optimal care for patients with stigma-associated conditions such as AIDS. As contributors to healthcare, students’ willingness to use specific procedures allows for the identification of areas of concern that can be focused on during training to optimise behaviour in managing PLWA or any other contagious disease. The literature shows that previous studies indirectly investigated medical and dental students’ willingness to care for PLWA using global attitudinal items. None of these studies utilised clinical scenarios to elicit willingness responses.[5,9,11,13-17] Only a few studies assessed willingness towards procedures such as mouth-to-mouth resuscitation.[8,10] Therefore, the aim of our study was to assess medical and dental students’ willingness to perform specific common procedures during medical and dental care of PLWA.

Materials and methods Sample

Participants in this study were medical and dental students in the last two years of their professional training at the College of Medical Sciences, University of Maiduguri, Borno State, Nigeria,who were willing to participate. A total of 304/385 students surveyed returned their questionnaires, translating to a response rate of 78.9%.

Instrument

A two-part 21-item questionnaire designed by Held,[18] and adapted by Balogun et al.,[19] was used in this study. Part 1 elicited sociodemographic information on previous experience with PLWA and previous AIDS educational instructions. Part 2 elicited students’ willingness to perform five selected techniques or procedures or care unique to their discipline on a 5-point Likert scale, ranging from strongly willing (1) to strongly unwilling (5). All five items on the subscale were worded positively to minimise the inherent contamination and response shift bias due to social desirability phenomena.[20] The minimum and maximum scores for the subscale were 5 and 25, respectively, and the higher the subjects’ total score, the less the willingness to provide services for PLWA. Held[18] and Balogun et al.[19] reported reliability coefficients of 0.80 and 0.76, respectively, for the willingness subscale of the instrument. In a separate Nigerian study, Oyeyemi et al.[21] reported correlation coefficients ranging between 0.72 and 0.88 for the subscales of the instrument, including the willingness subscale. The willingness subscale for medical students was adapted from a scale used to assess physicians’ willingness in a previous study,[7] while the willingness subscale for dental students was developed by the authors in collaboration with experienced dental practitioners in a teaching hospital. The content of the final document was judged to have face validity by two lecturers in the discipline.

Procedure

A sample of convenience comprising medical and dental students in the College of Medical Sciences, University of Maiduguri, participated in this survey. The questionnaire was handed to the students in their lecture halls at the University of Maiduguri Teaching Hospital after lectures on topics unrelated to AIDS. Prior to the study, ethical approval was obtained from the University of Maiduguri Teaching Hospital Ethical Committee. Anonymity was assured, while participants were also informed in a cover letter that completion and submission of the survey form implied consent.

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Data analysis

Using SPSS version 16, descriptive statistics of means and percentages were computed and analysis of variance (ANOVA) and independent t-tests were used to determine the influence of sociodemographic variables on willingness. Multiple regression analyses determined the predictors of willingness to perform procedures. Proportional differences were explored using chi statistics. Differences were considered significant at an alpha level of 0.05.

Results

The students’ mean age was 24.9 (SD±2.6) years. A total of 188 (61.8%) were male, 116 (38.1%) were female, and 218 (71.7%) did not personally know anyone living with HIV/AIDS. Approximately 154 (51%) had previously been asked to provide care to PLWA, 182 (59.9%) had experience in caring for PLWA, and 300 (98.7%) had received instructions on HIV/AIDS. Furthermore, 270 (88.8%) would care for PLWA if asked to do so. Medical students tended to have been asked to care for PLWA more frequently (chi statistic = 12.15; p<0.001) and had more previous encounters with PLWA (chi statistic = 85.25; p<0.001) than dental students (Table 1).

Willingness to care for PLWA

The majority of medical students were willing to perform venepuncture (n=174; 75.3%) and insert arterial lines (n=17; 74.0%), while 143 (61.9%) were not willing to perform mouth-to-mouth resuscitation on PLWA. A total of 126 (55%) medical students were willing to perform vaginal examinations, while 160 (69.2%) would assist with surgery for PLWA. Among dental students, 58 (78.8%) were willing to perform impression casting, while almost half (n=35; 48%) were unwilling to assist with an operation. Only about 60% were willing to perform scaling and polishing (n=43; 59.6%,), and 25 (34.6%) and 34 (46.2%) were unwilling to perform tooth extractions and root canal therapy, respectively (Table 2). The students’ mean overall willingness score was 13.4±4.0 out of a possible total score of 25. Overall, medical students were either willing or undecided on responses with regard to performing venepuncture (2.2±0.9), inserting arterial lines (2.3±1.0), and performing surgery (2.4±1.1), while they were more undecided than willing to perform vaginal examinations (2.7±1.1). However, these students were mostly unwilling to perform mouth-to-mouth resuscitation on PLWA (3.9±1.1). Overall, dental students were willing to do impression casting (1.9±0.9) and willing or undecided to perform scaling and polishing procedures (2.6±1.2).They were mostly undecided about performing tooth extractions (2.9±1.1) and root canal therapy (3.2±1.2) and in assisting during operations (3.1±1.3). Medical students’ willingness was significantly lower (p<0.001) to perform mouth-to-mouth resuscitation compared with other procedures. For dental students, there was no significant difference (p>0.05) between willingness to do scaling and polishing and tooth extractions; however, there was a significant difference between these and other procedures. Also, willingness to perform impression casting was significantly better (p<0.05) than willingness to carry out other procedures. Furthermore, there was no significant difference (p>0.05) with regard to willingness to assist with surgery and perform root canal therapy. There was a significant difference (p<0.05) between carrying out these tasks and others such as scaling and polishing, tooth extraction and impression casting (Table 2).

Research (mean = 13.73 v. 11.21). Students who know a family member with AIDS were more willing to care for PLWA (p<0.05) than those who did not (11.9 v. 15.2). Across both disciplines, those with previous experience of caring for AIDS patients were more willing to care for PLWA than their counterparts who had not had any previous contact with such patients (p<0.001). When asked, ‘Will you be willing to care for PLWA?’ students who answered positively were more willing to care for PLWA (p<0.05; mean = 13.4 v. 15.3 (medical); p<0.001; mean = 12.2 v. 16.8 (dental)) than those who answered negatively. Students who chose hospital practice as their long-term goal were more willing to care for PLWA (p<0.05; F=2.75 (medical); F=2.98 (dental)) than those who would prefer teaching. Those who were satisfied with instructions on AIDS were more willing to care for PLWA than those who were somewhat dissatisfied or not satisfied (p<0.05; F=3.78 (medical); F=2.91 (dental)). There was no significant difference in willingness by clinical year (p>0.05). In the final regression equation, knowing a family member living with AIDS was by far the strongest predictor of willingness (R2=0.22; p<0.001), followed in descending order by refusal to care for PLWA (R2=0.20; p<0.001) and long-term goal (R2=0.18; p<0.001).

Table 1. Students’ demographic characteristics and previous experience or encounters with PLWA (N=304) Medicine n (%)

Dentistry n (%)

Total n (%)

Male Female

147 (63.3) 84 (36.4)

41 (56.2) 32 (43.8)

188 (61.8) 116 (38.2)

Disciplines

231 (54.9)

73 (45.1)

304 (100)

Two

128 (55.4)

35 (47.9)

163 (53.6)

Three

103 (44.6)

38 (52.1)

141 (46.4)

130 (56.3) 101 (43.7)

24 (32.9) 49 (67.1)

23 (10.0) 208 (90.0)

Independent variable

Chi-statistic

p-value

17.053

<0.001

1.592

>0.05

154 (50.7) 150 (49.3)

0.053

>0.05

6 (8.2) 67 (91.8)

29 (9.5) 275 (90.5)

199.06

<0.001

146 (63.2) 85 (36.8)

36 (49.3) 37 (50.7)

182 (59.9) 122 (40.1)

11.842

168 (72.7) 63 (27.3)

50 (68.5) 23 (31.5)

218 (71.7) 86 (28.3)

57.316

209 (90.5) 22 (9.5)

61 (83.6) 12 (16.4)

270 (88.8) 34 (11.2)

183.211

Gender

Clinical year

Ever been asked to provide services for PLWA Yes No Ever refused to care for PLWA Yes No Ever cared for PLWA Yes No

0.001

Know of family member or another PLWA Yes No

<0.001

Will care for a PLWA if asked Yes No

<0.001

Ever received instructions on AIDS Yes No

Discussion

230 (99.6) 1 (0.4)

70 ( 95.9) 3 (4.1)

300 (98.7) 4 (1.3)

141 (61.0) 90 (38.9)

39 (53.4) 34 (46.5)

179 (58.9) 121 (39.8*)

<001 288.211

Satisfied with instructions on AIDS Yes No

96.658

<0.001

PLWA = people living with AIDS. *The subtotals do not add up to 304 because this phrase does not apply to those who did not receive any previous instructions on AIDS. On the items ‘Satisfied with instructions’, those who responded being either somewhat dissatisfied or dissatisfied were merged together as the group that responded ‘No’. Those who were satisfied or somewhat satisfied were merged together as the group that responded ‘Yes’. Clinical year three denotes the last year of training, while clinical year two denotes the penultimate year of training.

Influence of sociodemographic and previous encounters on willingness to care for PLWA The effect of sociodemographics on overall willingness score in each discipline was assessed. Among medical students, there was a significant difference in willingness by gender, with males being more willing to care for PLWA (p<0.05). There was also a significant difference (p<0.05) in willingness by religious affiliation, as students who subscribed to the Christian faith were more willing to care for PLWA than their Muslim

counterparts (mean score: Muslims = 13.08; Christians = 14.02). Moreover, students who answered ‘No’ to the question ‘Have you ever refused to care for PLWA?’ were more willing to care for PLWA (p<0.05) than those who answered ‘Yes’ (mean = 15.61 v. 13.37). Among dental students, there was no significant difference by gender and religion (p>0.05). However, students who answered ‘Yes’ to the question ‘Have you ever been asked to care for PLWA?’ were more willing to care for PLWA (p<0.05) than those who answered ‘No’

The majority (88.8%) of medical and dental students in this study were generally willing to care for PLWA if asked to do so. The proportion of dental students who were willing to provide oral health services to PLWA (88.8%) exceeds that of Nigerian dental students in previous studies in which only about 60% expressed willingness.[5,9] The proportion is also higher than or comparable to Nigerian dentists in two previous studies in which 63.6% and 78.4% of respondents, respectively, were willing to provide care to PLWA.[22,23] This proportion can almost be compared with that of dental students in the USA (83%),[24] while it exceeded that in Taiwan (49%),[13] India (75%),[11] Iraq (75.5%)[25] and Jordan (73.7%).[26] In the present study, the proportion of medical students (90.5%) who were willing to care for PLWA if asked is higher than the 85% reported by Tibdewal et al.[11] among Indian medical students. It is higher than that reported among Nigerian doctors (82%), in whom willingness was assessed using the same scale as in the

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Research

Table 2. Willingness to care for PLWA in each discipline Items

Willing n (%)

Undecided n (%)

Unwilling n (%)

Mean (±SD)

126 (54.5) 160 (69.2) 171 (74.0) 174 (75.3) 37 (16.0)

49 (21.2) 30 (13.0) 41 (17.7) 39 (16.9) 51 (22.1)

56 (24.2) 41 (17.8) 19 (8.2) 18 (7.8) 143 (61.9)

2.7 (1.1)a 2.4 (1.1)a 2.3 (1.0)a 2.2 (0.9)a 3.9 (1.1)b

43 (59.6) 21 (28.8) 58 (78.8) 30 (40.4) 28 (38.5)

13 (17.3) 18 (25) 8 (11.5) 18 (25) 10 (13.5)

17 (23.1) 34 (46.2) 7 (8.6) 25 (34.6) 35 (48.0)

2.6 (1.2)c 3.2 (1.2)b 1.9 (0.9)a 2.9 (1.1)c 3.1 (1.3)b

Medicine Perform vaginal examination Perform surgical operation Insert arterial lines Perform venepuncture Perform mouth-to-mouth resuscitation Dentistry Perform scaling and polishing Perform root canal therapy Perform impression casting Carry out tooth extraction Assist with surgical operation

PLWA = people living with AIDS. ‘Willing’ denotes respondents who were either willing or strongly willing to perform a procedure or technique or provide care. ‘Unwilling’ denotes respondents who were either unwilling or strongly unwilling to perform a procedure or technique or provide care. The lower the mean score, the better the willingness. Means with different superscripts are significantly different (p<0.05) from each other, while those with the same superscript are not.

present study.[7] Only 16.0% of medical students were willing to perform mouth-to-mouth resuscitation on PLWA compared with 24%[10] and 72%[8] reported among medical students in India and the USA, respectively. The proportion of medical students willing to assist with surgery is comparable to the 60% reported by Mohsin et al.,[10] but slightly lower than the 71% reported by Kermode et al.[2] in a study among healthcare workers in rural India. Overall, medical students were more willing to perform non-invasive procedures, such as venepuncture, and insert arterial lines, than performing vaginal examinations, which is considered to be an invasive procedure. Dental students were also more willing to carry out less invasive procedures such as impression casting and scaling and polishing than root canal therapy and tooth extractions, which are considered to be invasive. This finding is consistent with that of Mohsin et al.,[10] who reported an unwillingness among medical students to carry out invasive procedures involving AIDS patients. Medical students were more willing to assist with surgery than dental students (69.2% v. 38.5%), probably because more of the former had previous experience of caring for PLWA (63.2% v. 49.3%). The influence of religious affiliation on willingness to perform procedures is in agreement with the findings in one previous study that reported a more positive attitude among Catholics than Jewish students.[19] Previous experience of working with AIDS patients was also associated with

an increased willingness to care for PLWA, a finding consistent with a recent report among Nigerians doctors,[7] but at variance with one previous study on allied health professional students.[8]

Limitations of this study

This single-centre study has limitations in terms of the generalisability of the findings. Its results should be interpreted with caution because the students’ responses could have been affected by social desirability phenomena,[18] in which the students answered questions based on what they presumed is socially desirable. Furthermore, the apparent disparity between students’ responses is evidenced by the overwhelming majority of them indicating that they would care for PLWA if asked and their overall disposition that rates were undecided in 3 of the 5 procedures. This highlights the difficulty in predicting behaviour, and therefore the findings of this study should be interpreted cautiously.

Conclusion

The cohorts of medical and dental students in the present study were willing to care for PLWA if asked, but may be reluctant with regard to performing some common procedures on PLWA. These students were more willing to carry out less invasive procedures than those which they considered to be invasive ones. Previous personal encounters with PLWA, satisfaction with instructions and answering ‘Yes’ to the question ‘Are you willing to care for PLWA?’ influence students’ willingness to perform

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procedures on PLWA. Preferred practice settings, previous refusal to care for PLWA when asked, and knowing a family member or some other PLWA combined, predict willingness. This study suggests that extensive use of clinical clerkships and exposure through direct experience can enhance students’ disposition to perform procedures on PLWA. References 1. Marchal B, De Brouwere V, Kegels G. Viewpoint: HIV/AIDS and the health workforce crisis: What are the next steps? Trop Med Int Health 2005;10(4):300-304. 2. Kermode M, Jolley D, Langkham B, Thomas MS, Croft N. Occupational exposure to blood and risk of bloodborne infection among healthcare workers in rural north Indian healthcare settings. Am J Infect Control 2005;33(1):34-41. 3. Islam MT, Mostafa G, Bhuiya AU, Hawkes S, de Francisco A. Knowledge on, and attitude toward HIV/AIDS among staff of international organization in Bangladesh. J Health Popul Nutr 2002;20:271-278. 4. Al-Mazrou YY, Abouzeid MS, Al-Jeffri MH. Knowledge and attitudes of paramedical students in Saudi Arabia toward HIV/AIDS. Saudi Med J 2005;26:1183-1189. 5. Oboro H, Azodo C, Sede M. Perception of HIV/AIDS patients among pre-clinical dental students. Int J Infect Dis 2008;12(Suppl 1):e158. 6. McCarthy GM, Koval JJ, MacDonald JK. Factors associated with the refusal to treat HIV-infected patients: The results of a national survey of dentists in Canada. Am J Public Health 1999;89(4):541-545. 7. Adetoyeje Y, Oyeyemi BO, Bello IS. Physicians and AIDS care: Does knowledge influence their attitude and comfort in rendering care? Afr J Health Sci 2007;14:37-43. [http://dx.doi.org/10.4314/ajhs. v14i1.30844] 8. Kopacz DR, Grossman LS, Klamen DL. Medical students and AIDS: Knowledge, attitudes and implications for education. Health Educ Res 1999;14(1):1-6. 9. Azodo CC, Ehigiator O, Oboro HO, et al. Nigerian dental students’ willingness to treat HIV-positive patients. J Dent Educ 2010;74:446-452. 10. Mohsin S, Nayak S, Mandaviya V. Medical students’ knowledge and attitude related to HIV/AIDS. Nat J Comm Med 2010;1(2):146-149. 11. Tibdewal H, Barad P, Kumar S. Comparing dental and medical students’ knowledge and attitudes toward hepatitis B, C and HIV infected patients in India – a cross-sectional study. J Int Oral Health 2009;1:20-32. 12. Ahmed SI, Hassali MA, Abdul NA. An assessment of the knowledge, attitudes, and risk perceptions of pharmacy students regarding HIV/ AIDS. Am J Pharm Edu 2009;73(1):15. 13. Hu SW, Lai HR, Liao PH. Comparing dental students’ knowledge of and attitudes toward hepatitis B virus-, hepatitis C virus-, and HIV-infected patients in Taiwan. AIDS Patient Care STDS 2004;18(10):587-593. 14. Nasir EF, Astrøm AN, David J, Ali RW. HIV and AIDS related knowledge, sources of information, and reported need for further education among dental students in Sudan – a cross sectional study. BMC Public Health 2008;8:286. [http://dx.doi.org/10.1186/1471-2458-8-286] 15. Harden RM. International medical education and future directions: A global perspective. Acad Med 2006;81(12):S22-29. 16. Erasmus S, Luiters S, Brijlal P. Oral hygiene and dental students’ knowledge, attitude and behaviour in managing HIV/AIDS patients. Int J Dent Hyg 2005;3(4):213-217. 17. Cohen LA, Romberg E, Grace EG, Barnes DM. Attitudes of advanced dental education students toward individuals with AIDS. J Dent Educ 2005;69(8):896-900. 18. Held SL. The effects of an AIDS education program on the knowledge and attitudes of a physical therapy class. Phys Ther 1993;73(3):156-164. 19. Balogun JA, Kaplan MT, Hoeberlein-Miller T, Anthony A, Lefkowitz R, Hsia L. Knowledge, attitudes, and willingness of junior healthcare professional students to provide services for patients with acquired immunodeficiency syndrome. J Phys Ther Edu 1998;12(1):57-63. 20. Anastasi A. Psychological Testing. 5th ed. New York, NY: Macmillan Publishing, 1982. 21. Oyeyemi Y, Oyeyemi L, Akinwale G, Aderibigbe I, Alaba O, Anjorin O. Knowledge and affective traits of physiotherapy students to provide care for patients living with AIDS. S Afr J Physiother 2010;66(3):1-6. 22. Uti OG, Agbelusi GA, Jeboda SO. Are Nigerian dentists willing to treat patients with HIV infection? Nigerian Dent J 2007;15(2):66-70. 23. Utomi IL, Onajole AT, Arotiba JT. HIV/AIDS: Knowledge and attitudes of dentists in South Western Nigeria. Nigerian J Health Biomed Sci 2008;7(1):36-41. 24. Seacat JP, Inglehart MR. Education about treating patients with HIV infections/AIDS: The student perspective. J Dent Educ 2003;67(6):630640. 25. Al-Naimi RJ, Al-Saygh GD. Knowledge, attitude and health behavior of dental students towards HIV patients. Al-Rafidain Dent J 2009;9(1):110-119. 26. Ryalat ST, Sawair FA, Shayyab MH, Amin WM. The knowledge and attitude about HIV/AIDS among Jordanian dental students: Clinical versus pre clinical students at the University of Jordan. BMC Research Notes 2011;4:191. [http://dx.doi.org/10.1186/1756-0500-4-191]

Research Understanding the learning styles of undergraduate physiotherapy students D Hess, BSc Physiotherapy; J M Frantz, PhD Department of Physiotherapy, University of the Western Cape, Bellville, South Africa Corresponding author: D Hess (hess.danelle@gmail.com)

Background. Undergraduate students at universities have different learning styles. To perform optimally, both they and their educators should be made aware of their preferred learning styles and problem-solving abilities. Students have different backgrounds, strengths, weaknesses, interests, ambitions, levels of motivation and approaches to studying and educators should therefore aim to become more aware of the diverse approaches to learning. Objective. To identify the various learning styles and problem-solving abilities of physiotherapy students at the University of the Western Cape, South Africa. Methods. Undergraduate physiotherapy students (N=246) who were registered for the 2012 academic year participated in the study. Three valid and reliable questionnaires, including the Index of Learning Styles (ILS), the Problem-Solving Style Questionnaire (PSSQ) and the Learning Style Questionnaire (LSQ), were used. Responses were analysed statistically to establish the association between learning styles and problem-solving ability. Results. A response rate of 72% was reported (n=177). For first-, second-, third- and fourth-year students the response rates were 65/85 (76%), 53/67 (79%), 31/58 (53%) and 28/36 (78%), respectively. Forty-five (25%) participants were male, 124 (70%) were female and 8 (0.04%) did not indicate their gender. The prominent learning styles were feeling (PSSQ), kinaesthetic (LSQ) and visual-verbal (ILS). Males were prone to using the kinaesthetic learning style and females to a more visual learning style. The feeling group constituted 47% of the sample (39% males and 43% females). Conclusion. The majority of students seem to learn by doing, although facts are important to them. It therefore might be important to first teach physiotherapy students concepts and then assist them to apply these in practice. AJHPE 2014;6(1):45-47. DOI:10.7196/AJHPE.226

Educational and cultural diversity are important factors to consider in undergraduate physiotherapy education. There are four principal aspects of student diversity, including learning styles, approaches to learning, orientation to studying and intellectual development.[1] For students to benefit most from their learning opportunities, they and the faculty should be aware of their learning styles and ability to solve problems.[2] Felder and Brent[1] state that students have different backgrounds, strengths, weaknesses, interests, ambitions, levels of motivation and approaches to studying. To enhance undergraduate physiotherapy education, educators should aim to become more aware of these diverse approaches to master new material.[3] Learning styles are a useful instrument to help students and researchers understand how to improve the way they learn and teach, respectively. Furthermore, it is important to know how students with different learning styles approach problem solving. Learning styles or preferences are multifaceted ways in which learners perceive, process, store and recall what they are trying to learn.[4] Studies on preferred learning styles among physiotherapy students were primarily conducted abroad in developed countries such as Canada and Australia.[2,5] The Canadian study determined the learning styles and problem-solving abilities of physiotherapy students from their second to fourth year of a physiotherapy programme.[2] Results revealed that the preferred style of learning among students in the 4-year undergraduate physiotherapy programme was to study the theory and then reflect on or experiment with it. Their perceived problem-solving ability was similar to that of other undergraduate students, and was not related to their learning style.[2]

The Australian study determined the learning style preferences among occupational therapy, physiotherapy and speech pathology students.[5] The authors reported that optimal learning environments should take into consideration how students learn. Although a consistent learning profile among this group of students could not be determined, the findings suggested that each profession attracts students with a range of learning styles. They highlighted the need to investigate correlations between learning styles, instructional methods, and academic performance of students in the health professions. In the present study the learning styles of a group of physiotherapy students at the University of the Western Cape, South Africa were investigated. However, according to Felder and Brent,[1] it is not possible to tailor oneâ&#x20AC;&#x2122;s teaching to suit every learning style or to teach with a one-sizefits-all approach, expecting all learners to benefit.

Methods

Research design

TheÂ studyÂ employed a quantitative, cross-sectional research design. Crosssectional studies are mostly used to determine prevalence; therefore this design was deemed appropriate.[6]

Participants

All registered undergraduate physiotherapy students (N=246) for the 2012 academic year at the University of the Western Cape were invited to participate (Table 1).

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Research Data collection

Three questionnaires were used to collect the data, including the Index of Learning Styles (ILS), the Problem-Solving Style Questionnaire (PSSQ) and the Learning-Style Questionnaire (LSQ). The ILS was developed in 1991 and is based on the learning style model formulated by Felder and Silverman.[1] This questionnaire assesses preferences on four dimensions: active-reflective, sensing-intuitive, visual-verbal and sequential-global. The PSSQ places the student in one of four categories, i.e. sensing, intuitive, feeling or thinking.[7] In addition, the LSQ classifies the student into three possible groups, i.e. visual, auditory, and kinaesthetic learning styles.[8] All the questionnaires have been used in studies with similar population groups as the current study.

Data analysis

The data collected were captured and analysed using the Statistical Package for Social Science (SPSS) version 19.0. Descriptive statistics were used to summarise the frequencies of students in each learning style category and to determine whether the distribution of learning styles was different across the four years of the programme. Predominant race and gender were also determined. Inferential statistics using the independent sample test were employed to compare learning style scores across the four years of the programme and to analyse the association between learning styles and problem-solving ability. Table 1. Number of students registered in the programme (N=246) Year of study

Students, n

Male

Female

First

Second

Third

Fourth

Results

Demographic data

A response rate of 72% (n=177) was reported. For first-, second-, third- and fourth-year students the response rates were 65/85 (76%), 53/67 (79%), 31/58 (53%) and 28/36 (78%), respectively. Of the respondents, 45 (25%) were male, 124 (70%) were female and 8 (0.04%) did not indicate their gender. Of all participants who responded, 107 (60%) were coloured, 31 (18%) were white, and 26 (15%) were black. Thirteen students (7.3%) were grouped as ‘other’ and included Indians, Asians, and those who did not indicate their race.

Learning styles

An overview of the learning styles of the participants is presented in Table 2. Based on the results of the LSQ, more students were found to have a kinaesthetic learning style, followed by a visual learning style. Males seemed to prefer a kinaesthetic learning style (p<0.05), while females had a more visual learning style. There was no significant association between race and year of study and the learning styles. In the ILS questionnaire, the visual-verbal aspect of the students’ learning styles was more common (31%). In this category, females were more prone to this style of learning (p=0.00), and in the sequential-global category more males expressed a preference for this style (p=0.00). No significant gender and race differences were found between the other categories. In addition, there was a significant difference between senior-level (third- and fourthyear) and junior-level (first- and second-year) students, the former being more active-reflective learners. The PSQ highlighted that the majority of students 75/177 (42%) were classified in the feeling group. However, there was no significant association with gender and year of study. Within the thinking group, there was a significant association between gender and thinking, with males being more inclined to think matters through than females (p<0.005). Although there was no significant association found between the learning styles and the problem-solving ability of the participants, there was an association between

Table 2. Overall problem-solving and learning style No.

Questionnaire

Outcomes

Definition

Sensing

Problem- Solving Style Questionnaire

43/177

This questionnaire divides the group of students into 4 categories, i.e. sensing, intuitive, feeling and thinking

Intuitive

35/177

Feeling

75/177

[7]

Thinking 2

24/177

Learning-Style Questionnaire

[8]

Visual

64/177

Auditory

42/177

Kinaesthetic 3

This questionnaire groups students into three categories, i.e. visual, auditory and kinaesthetic

71/177

Index of Learning Styles

[8]

Active-reflective

37/177

Sensual-intuitive

45/177

Visual-verbal

55/177

Sequential-global

40/177

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This questionnaire assesses preferences in four dimensions (active/reflective, sensing/intuitive, visual/verbal, and sequential/ global) of a learning style model. Visual learners remember best what they see, i.e. pictures, diagrams, flow charts, time lines, films, and demonstrations. Verbal learners get more out of words, i.e. written and spoken explanations. Everyone learns more when information is presented both visually and verbally

Research the kinaesthetic type of learning style and the problem-solving method of feeling (Table 3).

Table 3. Association between problem-solving ability and learning styles (N=177)

Discussion

The current study assessed the learning styles and problem-solving approaches of undergraduate physiotherapy students registered at the University of the Western Cape. The students who were registered for the programme came from diverse cultural and socio-economic backgrounds, as indicated in the results. In addition, they were found to be more practically orientated, but still needed both visual and verbal cues. Gender influenced the learning style, with males seeming to process information in different ways than females. Males seemed to use more of a thinking process. This differed from another study, which focused on the learning styles of entry-level physiotherapy students. The results showed that these students preferred to learn new material by reviewing, observing or thinking as opposed to actively doing or planning.[9] In another survey, where gender and learning styles were assessed, there was a significant difference between the learning styles and gender.[10] The results of this study showed that styles leaning towards didactic teaching appealed more to males, as these are primarily abstract and reflective. It was also reported that females learned better in hands-on and practical settings, emphasising the sphere of the affective and doing. Therefore, the results of the study by Philbin et al.[10] show that when females are watching and feeling or doing and thinking they learn best, and when males are thinking and watching they learn best. Similarly, the current study reported that males tended to lean more towards thinking than females, who tended to be more visual. This indicates that females wanted to be stimulated visually by watching. Kolb’s theory states that a preferred learning style influences the problemsolving ability of a person.[2] Wessel et al.[2] further state that for students to make the most of their learning opportunity educators should be aware of their learning style and ability to solve problems. The study also assessed the learning style and problem-solving ability of students, and the results showed that there was no association between learning style and perceived problem-solving ability. The results from the current study were the same, even though more than one learning style questionnaire was used. Similarly to what was found in the present study, the learning style preferences of first-year undergraduate occupational therapy students in Australia demonstrated a greater preference for kinaesthetic learning.[11] This may indicate a preference for learning through practice or simulation. Even though a range of learning styles were found in the Australian study, instructional approaches seem to be required.[11] In contrast, Mountford et al.[9] found that entry-level physiotherapy students preferred to learn new material by reviewing, observing or thinking as opposed to actively doing.

Conclusion

Based on the three questionnaires used it was demonstrated that the majority of the students learn by doing, although facts are important to them. Therefore, physiotherapy students may learn better if the concepts they are taught in theory are applied in practice. This is supported by the fact that the highest number of students fell in the kinaesthetic learning style category. To effectively utilise this learning style, the educator should provide the learner with real-life experiences and simulations.

Problem-Solving Style Questionnaire Thinking

Intuitive

Sensing

Feeling

Learning-Style Questionnaire Visual

Auditory

Kinaesthetic

Active-reflective

Sensual-intuitive

Visual-verbal

Sequential-global

Index of Learning Style

Implications for practice

Lecturers should be aware of the different learning styles of students and address this either by changing their teaching practices or ensuring that their learning styles are used to their full effect. It is important to understand students and to be aware that they have different attitudes to learning. This should be used to create a teaching experience that will impact positively on the students’ learning experiences and for finding a balance between the extremes in each learning dimension.[1,12] All learning style preferences cannot always be accommodated but awareness can help to enhance methods of teaching and thus methods of learning.

Limitations

It must be emphasised that these results are an indication of the students’ learning preferences and an even better indication of the preference profile of a group of students (e.g. a class), but should not be over-interpreted. Acknowledgements. The authors would like to thank the National Research Foundation (NRF) for funding that allowed the first author to participate in a staff development programme and conduct an educational project.

References 1. Felder R, Brent R. Understanding student differences. Journal of Engineering Education 2005;94(1):57-72. 2. Wessel J, Loomis J, Rennie S, Brook P, Hoddinott J, Aherne M. Learning styles and perceived problem-solving ability of students in a baccalaureate physiotherapy programme. Physiotherapy Theory Practice 1999;15:17-24. [http://dx.doi. org/10.1080/095939899307865] 3. Carmo L, Gomes A, Pereira F, Mendes A. Learning styles and problem solving strategies. Paper presented at the 3rd E-Learning Conference; 7 - 8 September 2006, Coimbra, Portugal. 4. Lujan H, DiCarlo S. First-year medical students prefer multiple learning styles. Advan Physiol Educ 2006;30:13-16. [http://dx.doi.org/10.1152/advan.00045.2005] 5. Brown T, Cosgriff T, French T. Learning style preferences of occupational therapy, physiotherapy and speech therapy students: A comparative study. The Internet Journal of Allied Health Sciences and Practice 2008;6(3):1-12. 6. Mann C. Observational research methods. Research design II: Cohort, cross-sectional, and case-control studies. Emerg Med J 2003;20:54-60. [http://dx.doi.org/10.1136/emj.20.1.54] 7. Duff A. Note on the Problem Solving Style Questionnaire: An alternative to Kolb’s Learning Style Inventory? Educational Psychology: An International Journal of Experimental Educational Psychology 2004;24(5):699-709. [http://dx.doi.org/10.1080/0144341042000262999] 8. Cassidy S. Learning styles. An overview of theories, models, and measures. Educational Psychology: An International Journal of Experimental Educational Psychology 2004;24(4):419-444. [http://dx.doi.org/10.1080/0144341042000228834] 9. Mountford H, Jones S, Tucker B. Learning styles of entry-level physiotherapy students. Adv Physiother 2006;8:128-136. [http://dx.doi.org/10.1080/14038190600700278] 10. Philbin M, Meier E, Huffman S, Boverie P. A survey of gender and learning styles. Sex Roles 1995;32(7/8):485-494. 11. French G, Cosgriff T, Brown T. Learning style preferences of Australian occupational therapy students. Australian Occupational Therapy Journal 2007;54:58-65. [http://dx.doi.org/10.1111/j.1440-1630.2007.00723.x] 12. Montgomery S, Groat L. Student learning styles and their implications for teaching. In: Friesen E, Kristjanson C, eds. Teaching at the University of Manitoba. Winnipeg, Man: University Teaching Services, 1998;10:1-8.

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Research Health-promoting schools as a service learning platform for teaching health-promotion skills L M du Plessis,1 M Nutrition; H E Koornhof,1 M Nutrition; L C Daniels,1 M Public Health; M Sowden,1 M Nutrition; R Adams,2 CPN 1

Community Nutrition, Division of Human Nutrition, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

School Health Services, Department of Health, Provincial Government of the Western Cape, South Africa

Corresponding author: L M du Plessis (lmdup@sun.ac.za)

Background. Health sciences students have traditionally been taught their practical skills in community health facilities. However, clinics and hospitals are not necessarily ideal settings for teaching students health-promotion skills. Objective. To explore health-promoting schools (HPSs) to teach Stellenbosch University (SU) undergraduate dietetic students health-promotion skills. Methods. In this descriptive, cross-sectional study, students completed structured reflective journals and conducted interviews with teachers. The chief professional nurse interviewed the school principals. Results. The students were positive about HPSs, but only fully understood its implementation and practice after entering the school setting. They felt that they could play a role in increasing its efficacy. The teachers were positive about the initiative and thought that they had adequate knowledge to take it further, but were open to gaining more knowledge and insight. Teachers and students had similar views on the role that students could play in HPSs, including educating learners, parents and teachers on health and nutrition, assisting with growth monitoring and promotion, developing educational tools, obtaining various resources for schools, planning menus, budgeting for meals, and growing vegetables. Resources required by the schools could best be addressed by a team of healthcare professionals in collaboration with government departments and with community support. Conclusion. HPSs offer extensive opportunities where SU undergraduate dietetic students, and possibly other healthcare profession students, could serve the needs of communities while learning and practising health-promotion skills. AJHPE 2014;6(1):48-51. DOI:10.7196/AJHPE.250

We live in a world of problems which can no longer be solved by the level of thinking that created them. – Albert Einstein

Frenk et al.[1] highlighted that professional health education has not kept pace with current global health challenges. Fragmented, outdated and static curricula were largely to blame for producing ill-equipped graduates. Re-design of professional health education is therefore necessary and timely. Service learning is an educational method enabling students to learn and develop through active participation in thoughtfully organised service experiences that meet actual community needs.[2] Howard[2] identified three criteria for service learning: a relevant and meaningful service provided to the community; enhanced academic learning for students; and a structured opportunity for reflection. Bringle and Hatcher[3] pointed out that students should reflect on activities to gain a deeper understanding of module content, gain a broader appreciation of their discipline, and enhance a sense of personal values and responsibilities. Traditionally, medical schools attempted to meet the bulk of their students’ practical learning outcomes in healthcare facilities. In South Africa, the burden of disease and the focus on strengthening of the primary healthcare (PHC) service delivery in the country necessitate a move away from curative services to preventive approaches, with health promotion at the core, now more than ever before. This strengthening includes a shift from health facility-based services to community-based services. However, clinics and hospitals are not necessarily ideal settings for health promotion, as the target audience may not be ready to receive information and learn

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new skills, and waiting areas are often overcrowded. Therefore, these settings are not conducive to teaching students health-promotion skills. The question arises where health sciences faculties should place their students to teach them the necessary skills and empower them to fully understand and perform health promotion. From the perspective of a settings-based approach to health promotion, schools could be an ideal service-learning platform, considering that children constitute a large population and schools are accessible over prolonged periods of time. Schools are recognised places of learning, with existing structures and systems that provide opportunities for the integration of new knowledge and skills into the regular curriculum in an acceptable and a cost-effective manner. Furthermore, the informal or ‘hidden’ curriculum of a school can significantly influence learners’ attitudes and behaviours. Schools have the potential for accessing nearly the entire population of young people, including minority and disadvantaged groups.[4] Learners can be reached at an influential stage, i.e. childhood and adolescence, and a school is a relatively sheltered learning environment. In the school setting education and learning are the norm and the wider community can be influenced, i.e. school personnel, families and community members. In 1995, the World Health Organization (WHO) launched its Global School Health Initiative of health-promoting schools (HPSs). An HPS is defined as ‘a school that is constantly strengthening its own capacity as a healthy setting for living, learning and working’.[5] The foregoing

Research initiative aims to advance the health of the community by using the school as a platform for health promotion and education. This may ultimately improve the health of school personnel, families, learners and the wider community, as nutritional education and promotion is a cardinal element in an HPS.[5] According to Waggie et al.,[6] many educators do not initiate or sustain the concept of HPSs. It is viewed as an additional task by which they are not assessed, and which is the duty of the Department of Health and Welfare. The WHO, however, states that in every country collaboration between the Department of Education and Department of Health is crucial for the HPS concept to succeed. Although the health sector has a longstanding relationship with schools, usually in screening and treating learners – while occasionally engaging in preventive measures[7] – the health and education agendas of schools are often in competition with each other. Schools’ agendas are filled with educational material and teachers often struggle to find time to cover health topics.[8] The literature suggests that school health services could be more effective if attention is paid to working collaboratively on partnerships and if school health services are integrated with other components of an HPS. More successful partnerships are possible, but need both the education and health sectors to work more closely together to develop organisational and interventional strategies consistent with the needs of the school community.[7] The newly launched South African Integrated School Health Policy (ISHP) was developed jointly by the Department of Basic Education and Department of Health. This policy recognises the HPS concept as a key component of its programme and focuses on the importance of nutrition.[9]

Objective

BSc Dietetics students at Stellenbosch University (SU) follow a 4-year undergraduate course. During their internship, 4th-year students do a 6-week Community Nutrition rotation in an urban setting. In deliberation with the Western Cape Government: School Health Services, a servicelearning agreement was formulated to include a week-long HPS exposure in the students’ community experience. This exposure includes assisting the school health team (consisting of a chief professional nurse, a professional nurse and an enrolled nurse) by weighing and measuring Grade 1 learners as part of routine school health screening to assess early indications of growth problems. Thereafter, students interpret the anthropometry and suggest appropriate action, where applicable. They perform a health education and promotion session with Grade 1 learners as well as an advocacy presentation on the dietetics profession to secondary school learners. The aim of this study was to assess the experiences and opinions of 4th (final)-year dietetic students with regard to HPSs as a setting to learn about health promotion and to identify opportunities in which they could play a role in optimising the HPS initiative. Furthermore, knowledge, attitudes, beliefs and practices (KABP) of teachers and school principals regarding the HPS initiative and the role of nutrition in health were assessed.

Methods

Study design and population

A descriptive, cross-sectional study was conducted in the western border area of the Cape Town City District, Western Cape, South Africa. The study population consisted of 4th-year SU dietetic students (N=17), teachers (N=30) and school principals (N=10) from 10 selected primary schools in a low socio-economic community, who consented to participate.

Data collection methods

Reflective journals. Students were requested to write structured reflective journals regarding their experiences during the week of service learning in a school setting. Questions students had to answer, or statements they had to consider in the reflections, included: their experience of the platform and how this influenced their thoughts/perceptions regarding the school setting as a service-learning platform for student training; the role they could play in the school environment; and whether the school(s) they visited required any additional resources to implement the HPS initiative. They could also share additional thoughts they considered to be valuable. KABP survey. A questionnaire used for the structured interviews with teachers and school principals consisted of 12 open-ended and three closedended questions addressing the following aspects: • Knowledge of the concepts of healthy nutrition and malnutrition and how these can be addressed in the school and community settings. • Attitude towards and knowledge about the HPS initiative. • Beliefs regarding health-related knowledge and training needed in this regard. • Practices to improve their schools’ health knowledge. The students acted as field workers and interviewed the teachers, while the chief professional nurse (co-investigator) interviewed the school principals. Students were standardised in terms of ‘prompts’ for the interviews.

Pilot study

A pilot study was conducted in one of the schools in the study area to test the face and content validity of the questionnaires. These results were excluded from the study data. Minor adaptations were made to the questionnaires after the pilot study.

Data analysis

Qualitative data from the reflective journals and responses to the openended questions were regarded as transcribed text. The text was coded manually by two researchers to identify themes. Themes were induced and established into units of meaning or codes. The data were read and re-read and notes were made to illustrate links between different themes and codes. The two researchers compared their findings and discussed different interpretations to reach consensus.

Ethical and legal aspects

Ethics approval to conduct the research was obtained from the Health Research Ethics Committee of the Faculty of Health Sciences, Stellenbosch University (Ref.: N10/02/039). Participation was voluntary and all participants were required to provide written informed consent before the study. Coding of each questionnaire ensured anonymity and confidentiality of the participants.

Results

The results were divided into two broad themes, i.e. experiences and opinions of undergraduate dietetics students; and knowledge, attitude and behaviour of the teachers and school principals. Within the themes, seven categories emerged: (i) a positive attitude to HPSs; (ii) the students’ role in HPSs; (iii) community outreach; (iv) resources required (common themes); (v) importance of service-learning experience (students); (vi) suitability of

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Research platform (students); and (vii) staff knowledge levels. There was an overlap of four of the categories in the two themes.

Experiences and opinions of undergraduate dietetic students

The students were positive about the HPS initiative, even before entering the schools, but only fully understood its implementation and practice when they worked in the school setting and engaged with schools that had been exposed to the initiative. ‘I think that this last week was a brilliant learning experience for us. Only once health promotion in schools was seen in practice did I fully grasp the theory of it.’ ‘Without this experience I would never have properly understood health promotion this well, thus I feel that it is an amazing platform for student training.’ ‘This experience made me realise the crucial need for … taking part in health promotion above just learning of the concepts.’ The students were of the opinion that schools are a good platform to instil nutritional concepts and basic health skills in young children, as the learners are an available and receptive target audience. They enjoyed the interaction with the eager learners and sensed the beneficial effect of health promotion on the learners, their families and the broader community. ‘This [exposure] proves once again to us students that there are ways to make changes in society.’ ‘The exposure to health promotion in schools made me realise that us as healthcare workers have to engage in the community and help them to help themselves.’ The students felt that they had a role to play in increasing the efficacy of this initiative and suggested becoming involved in educating learners, parents and teachers in health and nutrition. Suggestions were made about how they could assist with growth monitoring and promotion, developing educational tools for use in the classrooms, planning menus, budgeting for meals for the school feeding schemes, advising on tuck shop items, and lending a hand with training in vegetable gardening. ‘We can design and create teaching tools regarding healthy lifestyles and nutrition and we can teach the children in creative ways.’ ‘I think our role with regard to the weighing and measuring helps with the identification and the assessment of the school’s nutritional status. The information that we provide can help with the early prevention measures … ’ Resources needed by the schools, as noted by the students, included: a dietician who visits the schools once a week, nutritional education tools, funds, sports grounds, an equipped kitchen, first-aid kits, volunteers and proper sanitation.

KABP of teachers and school principals

Teachers described HPSs as a concept applied in schools where healthy eating habits and lifestyles are promoted, including the physical, mental and emotional well-being of learners. The link between a hungry child and subsequent poor school performance was also mentioned. 'You can’t teach a hungry child.’ Teachers had a basic understanding of the concept of healthy nutrition, but struggled to describe malnutrition correctly. Overall, the teachers were positive about and supported the HPS initiative. Factors contributing to their attitudes included remarks about

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well-fed children concentrating better, improving school facilities and personal hygiene, producing vegetables in school gardens, providing support to poor families and increasing children’s self-esteem. They felt that they had enough knowledge to apply the HPS initiative, but were open to gaining more knowledge. A few teachers agreed that they lacked knowledge about the initiative. Areas in which training was needed included first aid, healthy living, intervention strategies from specialists with health knowledge and nutritional requirements of children. Teachers responded that dietetic students have a role to play in HPSs by assisting with growth monitoring, alerting parents to nutritional problems, educating learners, teachers and parents about nutrition, as well as developing nutritional education tools. ‘The students’ presence makes the children feel special and helps the school healthcare team’s work load to be lighter.’ Resources needed, as identified by teachers, included first- aid, screening and sports equipment, nutritious food for the National School Nutrition Programme (NSNP), vegetable seeds, and health resources. Financial assistance, a designated plate and suitable cutlery for each child, and volunteers to assist with food preparation for the NSNP were also listed. Teachers believed that the HPS initiative could improve the nutritional status of their community. Examples were addressing parents on such issues at parent-teacher meetings, and vegetable gardens and soup kitchens run by the school to assist the vulnerable and elderly in the community.

Discussion

The need to shift the healthcare focus in South Africa from curative to preventive, with health promotion at the core, has been expressed. The recently launched ISHP envisages optimal health and development of school-going children and the communities in which they live and learn. [9] This vision supports the necessity to strengthen the HPS initiative in the country. In an attempt to align the SU BSc Dietetics Community Nutrition curriculum with actions required from these relevant and updated policies, the authors investigated the school setting as a location where future dieticians could be taught the necessary skills to perform health promotion. In this study the students indicated that they only fully understood the HPS initiative after they had been exposed to it. This illustrates that practical exposure to real-life health promotion scenarios should be an essential element of the professional health education curriculum. By observation and reflection students identified and reported concrete examples of health-promotion activities where they could become involved in furthering the initiative. Dharamsi et al.[10] explored the international service-learning experience of three medical students and the value of critical reflection. In their study, students kept reflective journals and wrote essays including detailed accounts of their experiences. Students noted an increasingly meaningful sense of what it entails to be vulnerable and marginalised, to create a heightened level of awareness of the social determinants of health and the related importance of community engagement, as well as developing a deeper appreciation of the health advocacy role and key concepts embedded within it. The reflective journals completed by the dietetic students in the study indicated that the criteria for service learning can be met when utilising the HPS as a service-learning platform.[2] The lecturers’ response to the need for providing students with the opportunity to improve skills building in preventive healthcare therefore proved to be of value.

Research Ridge et al.[8] highlighted an array of changes that take place in HPSs. These include changes for the learners (e.g. increased awareness of health, happier learners who feel cared for, improved learning outcomes and health practices); changes for the school (e.g. proactive health strategies, improved staff morale, improved health and physical environment); and changes in community links (e.g. better networking, increased involvement and satisfaction of parents). The health-promotion skills acquired by students in the study included early health assessment for preventive action, and nutritional education and promotion in schools. The students and school staff could identify more opportunities where the students’ input could positively contribute to the improvement in the school nutritional environment, ultimately resulting in further healthy lifestyles in the school community. The reciprocity established between the school health service team, students, teachers and learners through this service-learning agreement can partially explain the overall positive attitude noted by students and teachers towards the HPS initiative. A systematic review by Wang en Stewart[11] concluded that there is a need for more professional training for teachers in the HPS approach, as well as more qualitative studies to assess future school-based nutritional promotion programmes. An evaluation of HPSs in Hong Kong by Lee et al.[12] found that there was insufficient staff training in health promotion and education. Teachers can be perceived as role models for students and are central to a school’s functioning; hence interventions involving students may potentially change the health-risk behaviours of teachers. Schools also provide a valuable link with parents and the community. Involvement of parents, caregivers and local community members can act as strong reinforcement and support for strategies implemented in schools.[4] In the schools included in this study, the teachers and school principals could identify their own shortcomings and needs to optimise the HPS initiative. They expressed their willingness to learn more and voiced concrete ideas of how the school community could benefit from the students’ involvement. Furthermore, teachers were willing to work with the students and were eager to learn more. Individuals and communities often have complex health needs and typically require professional inputs from more than one discipline to address issues regarding their health.[13] In 2001, a recommendation by the Institute of Medicine Committee on Quality of Health Care in America suggested that healthcare profession teams can best communicate and address these complex and challenging needs.[14] The resources needed by the schools, as identified by the students and teachers in this study, should be addressed by such a team. The HPS platform furthermore lends itself to establishing opportunities for intraprofessional learning and teaching. With concerted efforts from different sectors (e.g. medical, dental, occupational therapy, physiotherapy, speech and audiology, nursing and dietetic students, as well as trans-faculty involvement), schools could be supported to access more resources and receive expert advice on best practice intervention strategies to further the health and well-being of the school community. This interprofessional approach may allow sharing of expertise and perspectives towards the common goal of restoring or maintaining an individual’s health and improving outcomes while combining resources.[15]

Conclusion and recommendations

The new ISHP embraces a comprehensive approach to ensure the health of all learners. Higher education institutions have a responsibility to engage with communities and assist in addressing their needs. Service learning is one way of fostering such engagement in a structured, practical way. An HPS service-learning agreement offers abundant opportunities for undergraduate SU dietetic students for health-promotion activities. This exposure should be extended to students of other healthcare professions.

Limitations

Using the students to conduct the interviews with the teachers as well as using reflective journals as a data collection instrument, could have led to incomplete data gathering owing to their limited experience in conducting research. Acknowledgements. The authors wish to thank the SU BSc Dietetics fourthyear class of 2010, the Metro Western Health District: School Health Services personnel – Claudette September and Pat Scheffers – as well as the principals, teachers and learners who participated in the research. Mrs M L Marais is acknowledged for proofreading the manuscript. This research was supported by grants received from the SU Fund for Innovation and Research into Learning and Teaching (FIRLT) and the SU Faculty of Medicine and Health Sciences, Research Development and Support, Term Post for Allied Health Professions, Research Assistance.

References 1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/S01406736(10)61854-5] 2. Howard J. Service-learning Course Design Workbook. University of Michigan: Edward Ginsberg Center for Community Service and Learning, 2001:10-12. 3. Bringle RG, Hatcher JA. Implementing service learning in higher education. Journal of Higher Education 1996;67(2):221-239. 4. Lynagh M, Schofield MJ, Sanson-Fisher R. School health promotion programs over the past decade: A review of the smoking, alcohol and solar protection literature. Health Promotion International 1997;12(1):43-60. 5. World Health Organization. Global school health initiative. http://www.who.int/school_youth_health/gshi/en/ index.html (accessed 7 October 2013). 6. Waggie F, Gordon N, Brijlal P. The school, a viable educational site for interdisciplinary health promotion. Educ Health 2004;17(3):303-312. 7. St Leger LH. The opportunities and effectiveness of the health promoting primary school in improving child health – a review of the claims and evidence. Health Education Research 1999;14(1):51-69. [http://dx.doi. org/10.1093/her/14.1.51] 8. Ridge D, Northfield J, St Leger L, et al. Finding a place for health in the schooling process: A challenge for education. Australian Journal of Education 2002;46:19. 9. National Departments of Health and Basic Education. Integrated School Health Policy. Pretoria: Department of Health, 2012. 10. Dharamsi S, Richards M, Louie D, et al. Enhancing medical students’ conceptions of the CanMEDS Health Advocate Role through international service-learning and critical reflection: A phenomenological study. Medical Teacher 2010;32:977-982. [http://dx.doi.org/10.3109/01421590903394579] 11. Wang D, Stewart D. The implementation and effectiveness of school based nutrition promotion programmes using a health promoting schools approach: A systematic review. Public Health Nutrition 2013;16(06):1082-1100. [http://dx.doi.org/10.1017/S1368980012003497] 12. Lee A, St Leger L, Cheng FF. Hong Kong Healthy Schools Team. The status of health-promoting schools in Hong Kong and implications for further development. Health Promotion International 2007;22(4):316-26. [http:// dx.doi.org/10.1093/heapro/dam029] 13. Bridges D, Davidson R, Odegard P, et al. Interprofessional collaboration: Three best practice models of interprofessional education. Medical Education Online 2011;16:6035. http://med-ed-online.net/index.php/meo/ article/view/6035/html_115 (accessed 7 October 2013). 14. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Ccentury. Washington, DC: National Academy Press, 2001. 15. Barker K, Oandasan I. Interprofessional care review with medical residents: Lessons learned, tensions aired – a pilot study. J Interprof Care 2005;19:207-214.

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Research Using graduates as key stakeholders to inform training and policy in health professions: The hidden potential of tracer studies A G Mubuuke, BMR, MSc, MHPE; F Businge, BMR; E Kiguli-Malwadde, MB ChB, MMed, MHPE Radiology Department, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda Corresponding author: A G Mubuuke (gmubuuke@gmail.com)

Background. Tracer studies are alumni surveys that attempt to track activities of graduates of an educational institution, which enable the contextualisation of these professionals through a dynamic and reliable system to determine their career progression. It also enables the gathering of information to feed back into training institutions and to inform policy bodies on key issues. The purpose of this study was to track career paths of radiography graduates in Uganda, examine their contribution to their profession, and establish their opinions on how to improve training and inform policy. Methods. A cross-sectional descriptive survey of radiography graduates who completed their training between 2001 and 2011 was conducted. Names of graduates were obtained from university records and contact details were sought from the register of the Uganda Radiographers Association, Facebook, Twitter, and friends. Data were collected using a self-administered questionnaire distributed electronically to the students. In a few instances, the survey was completed telephonically. Results. A total of 90 questionnaires were sent out; 72 (80%) were returned. The majority of the respondents (95.8%) were employed as radiographers at the time of the survey and were all satisfied with their work. A significant number were employed abroad, while those who remained in the country worked for private health facilities and only a few worked in government health facilities. Key suggestions were identified to improve training and influence policy. Conclusion. Graduate radiographers were generally satisfied with their current work. Many trained radiographers, however, are leaving the country, thereby creating a skills shortage in the government healthcare system. AJHPE 2014;6(1):52-55. DOI:10.7196/AJHPE.302

Tracer studies are alumni surveys that attempt to track activities of graduates of an educational institution. [1] According to Boaduo et al.,[2] tracer studies enable the contextualisation of graduates of a specific institution through a dynamic and reliable system in order to determine their career progression. Such studies also enable the evaluation of training provided by institutions, graduatesâ&#x20AC;&#x2122; career paths, nature and status of employment, professional and job satisfaction, and geographical distribution.[3] It is particularly important for policy makers to assess the presence, status and distribution of the health workforce within a country or region, which subsequently contributes to planning.[1] Health professions training institutions in Africa have paid much attention to transform and align training with the health needs of communities and current global trends.[4] For example, teaching and learning have been modified, moving away from the traditional didactic teacher-centred approach to the student-centred, competency based, community-orientated and transformative learning approaches. All of these are aimed at improving the quality of graduates and providing them with the necessary skills and competencies to address community health needs. Many health workers have completed this training. Consequently, evaluation studies have been conducted at training institutions in Africa and worldwide, aiming to further improve the training of future healthcare professionals. However, most of the aforementioned evaluation studies focus on the training process, including course delivery, materials, content, resources and tutor performance.[5] These evaluations normally culminate in curricular reviews and reforms facilitated by education experts, and graduates of

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these programmes are rarely consulted for their input. Often, faculty in training institutions are detached from the workplace environment of many healthcare workers, the latter frequently being in a better position to offer opinions on how the training needs to be adjusted to meet the required demands on ground level. Their responses can also gauge the level of satisfaction with the training in relation to work demands, which can assist trainers in initiating improvements in cases of dissatisfaction.[6] Schomburg[3] suggests the use of tracer studies as a method of acquiring useful information from graduates to feed back into the training process. Such information can be used to make the necessary adaptations to impart skills demanded in the work environment and to improve the quality of the training. It can also be used as a marketing tool for the institutionâ&#x20AC;&#x2122;s programmes.[7-11] Iloeje[12] reported that surveys of graduates are important tools for institutional development because of systematic feedback from former students. The opinion of former students and their retrospective assessment of the training are not only likely to stimulate curricular debates, which can be very useful to current or future students, but also to inform policy makers and institutions about the contribution of these professionals to national development.[13] The current study focused on tracing radiography graduates from Makerere University, Kampala, Uganda over a 10-year period. Radiography training at a Bachelors degree level in Uganda commenced in 2001 at Makerere University. Although training has been ongoing, there are no data regarding the career status of the graduates and the impact of their training on their lives or the healthcare system. The

Research graduates have also not been contacted to feed back their comments into the training programme for improvement of training. Therefore, the aim of this study was to track the career paths of radiography graduates to examine the retrospective contribution of their training to their current work demands and to use their views to improve the training of current and future students in an attempt to influence policy formulation in healthcare planning.

Methods

Study design

A cross-sectional descriptive study was conducted at the School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.

Participants and sampling

The study involved radiography graduates (N=90) who completed their training between 2001 and 2011. All were eligible to participate in the study and their names were obtained from Makerere University records. The contact details of the graduates were sought and obtained from multiple sources, including the register of the Uganda Radiographers Association, social media channels, e.g. Facebook and Twitter, and friends of former students.

Data collection

Data were collected using anonymised self-administered questionnaires distributed by e-mail to the graduates (N=90). Questionnaire items were developed by the researchers from an initial critical review of the literature on the subject. The questionnaire was then piloted with two graduates and improvements were made before administering it to ensure validity of the instrument. Information was sought regarding demographic information of the graduates, job placement profiles, factors vital to obtaining employment, and how the radiography curriculum was relevant to eventual job requirements.

Job placement profiles

All respondents were employed at the time of this survey. Table 2 illustrates job placement status and distribution at the time of the study. As all graduate radiographers were employed and satisfied with their work, it illustrates that the demand for radiographers in Uganda and beyond is currently high. All the respondents working in radiography and imaging or related work reported holding more than one radiography appointment simultaneously, and all of them reported working in major urban centres. Thirty (41.7%) reported practising radiography at three different venues. Those who left Uganda worked in Kenya, Cameroon, South Africa, Namibia, Australia and the UK. Therefore, many graduate radiographers left the country to work abroad, while those who remained worked for private health facilities, and very few sought employment in government health facilities. Of the three radiographers who were not engaged in radiography-related work, two were operating private businesses unrelated to radiography and imaging and one was engaged in agriculture. On the survey tool, these three radiographers reported poor remuneration as the major reason for engaging in other work. Table 1. Sociodemographic profiles Demography

% (n)

Gender Males Female

59.7 (43) 40.3 (29)

Age distribution (years) 25 - 29 30 - 34 >34

83.3 (60) 15.3 (11) 1.4 (1)

Marital status Married Single

16.7 (12) 83.3 (60)

Data analysis

Data were majorly quantitative and analysed by a statistician in the presence of the researchers. Responses from the questionnaires were tallied, coded, counted and entered into an Epi-Info statistical package to obtain percentages and frequencies, the final data being presented by means of descriptive statistics.

Table 2. Current employment and satisfaction status and distribution of radiographers

Ethical issues

The questionnaire did not identify the names of the respondents. They could opt out of te study at any one time. Data were kept securely and only accessed by the researchers. Ethical approval to conduct the study was granted by the Review Board, School of Medicine, Makerere University.

Results

Ninety questionnaires were sent out and 72 (80%) were returned.

Sociodemographic profiles

The demographic characteristics of the respondents are summarised in Table 1. All the respondents were registered with the Uganda Radiography Board and Allied Health Professionals Council. Being lawfully registered is therefore one manifestation that the qualification obtained was recognised and accredited by professional bodies.

Employment status

% (n)

Employed

100 (72)

Unemployed

0 (0)

Full- time employment

97.2 (70)

Part-time employment

2.8 (2)

Employment related to radiography/imaging

95.8 (69)

Employment not related to radiography/imaging

4.2 (3)

Satisfaction with employment Very satisfied Satisfied Less satisfied Dissatisfied Very dissatisfied

45.8 (33) 54.2 (39) 0 (0) 0 (0) 0 (0)

Distribution of radiography graduates Ugandan public facilities Ugandan private facilities Outside Uganda

5.8 (4) 68.1 (47) 26.1 (18)

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Research Regarding satisfaction with their current work, 84.7% (n=61) said they were happy and satisfied with their work. With regard to further training, 25% (n=18) had either acquired a postgraduate qualification or were engaged in postgraduate training, leaving 54 (75%) without postgraduate education.

Factors that contributed to obtaining employment

Fifty (69.4%) of the respondents said their study record had bearing on obtaining employment as radiographers, indicating that many employers still value the academic merit of graduates. Again, 50 (69.4%) said generic skills, including communication, interpersonal skills and problem-solving skills, were key to obtaining employment. Twenty (27.8%) respondents indicated that limited experience was a major factor affecting their employment prospects and 10 (50%) of these said they had to first perform volunteer work at their workplace before finally being offered full-time jobs.

Relevance and satisfaction with regard to curriculum subjects

The majority of the radiographers reported that various curriculum subjects were indeed relevant to their practice (Table 3). The majority of respondents were generally satisfied with most subjects of the radiography curriculum, except two areas, i.e. X-ray image interpretation and research skills. All 72 respondents commented that being graduates, employers expected more input from them in giving opinions on X-ray images. Community-based training courses were rated highly by the graduates. All respondents suggested that strengthening the research component in the radiography curriculum should be addressed, and 10 (13.8%) of them had been denied entering postgraduate studies owing to this. It can therefore be concluded that the curriculum is largely relevant to the current demands, but needs to be improved to address the identified gaps.

Discussion

The majority of the graduates were in their mid-20s - mid-30s as the study covered 2001 - 2011, bearing in mind that the radiography degree course started in 2001. More male than female graduate radiographers were trained during 2001 - 2011. Although admission criteria do not discriminate on the basis of gender, more males than females tend to work in science professions in Uganda. The majority of graduates were single, probably because many were establishing themselves and building up their careers. Regarding training, most respondents cited the crucial role of generic skills (e.g. communication, inter-personal skills, and problem solving), besides technical knowledge and skills, in obtaining employment. It is therefore important to inculcate generic competencies such as professionalism, inter-disciplinary training, leadership, management, communication and inter-personal skills during radiography training. Additionally, training of undergraduate radiographers needs to include basic aspects of image interpretation and reporting, research skills, independent student research projects, and more time for practical and clinical training. These are some of the key issues that need to be addressed urgently by, for example, curricular reviews. Former radiography students clearly supported community health courses in the radiography curriculum. They normally undertake these during community placements, together with students from other disciplines, e.g. medicine, nursing, dentistry and pharmacy. These courses focus mainly on primary healthcare activities, community settings and community

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Table 3. Satisfaction with radiography curriculum components Component

% (n)

Community health courses Research skills Plain radiography Fluoroscopy Computed tomography Ultrasound Mammography Magnetic resonance imaging Nuclear medicine Dental radiography Clinical/practical hours X-ray film interpretation/pattern recognition

100 (72) 27.7 (20) 100 (72) 100 (72) 100 (72) 100 (72) 76.4 (55) 66.6 (48) 68 (49) 100 (72) 62.5 (45) 13.8 (10)

empowerment. The explanation for the observed interest in such courses is probably because students are then exposed to work in rural communities, where they are likely to be employed, away from teaching hospitals. Additionally, students then have opportunities to interact closely with their colleagues from other disciplines, thus appreciating the role of teamwork in healthcare delivery. A significant number of graduate radiographers have left Uganda to go abroad, while the remaining few hold more than two radiography positions in their daily work schedule, mostly in private urban health facilities. Holding more than two jobs results from poor pay and the limited numbers of radiographers. This trend is not only limited to radiographers, but also applies to other health professionals and science graduates in Uganda. Many radiographers leave the country in search of training opportunities and career development. Few radiographers have the opportunity to pursue postgraduate studies for career growth, mainly because Uganda has had no accredited postgraduate programmes in this discipline. This drawback is found in many African countries outside South Africa. When radiographers leave for further training abroad, many never return, further constraining the remaining workforce. Therefore, training institutions, professional associations and other government bodies should initiate career advancement programmes locally. This is likely to reduce the number of radiographers who leave the country, as has been observed in other reported studies.[14] It is also possible for governments to formulate policies that call for rural community service programmes for newly qualified professionals, not only radiographers, but also other health professionals. In such a programme, new graduates can work in rural community facilities under supervision and be remunerated by government for at least a year before registration. This would benefit both the graduate and the government, with the former gaining much-needed experience and mastery of skills, and the latter maintaining a continued presence of health workers in underserved areas. It is implied that rural communities have a higher shortage of radiographers, as all respondents were working in the major urban centres. This could be because urban centres have more private health facilities and it is possible to be employed in more than one workplace. However, this study did not specifically set out to investigate disparities in radiographer distribution between rural and urban settings and the possible causes of such disparities. This is therefore an area that warrants further research.

Research This study has highlighted that alumni surveys can generate useful information to feed back into the training process, thus enhancing the quality of teaching and learning. Useful information can also be generated from tracer studies, which can assist in formulating policies aimed at retaining health workers in areas where they are most needed. Although this study focused on radiography graduates, some findings are also most likely applicable to many other health professions. The study has some limitations. Firstly, the researchers did not conduct individual interviews or focus group discussions to obtain qualitative experiences of the participants, mainly due to difficulties in accessing the participants physically. Perhaps in-depth qualitative interviews or focus group discussions would have provided more data to supplement the questionnaire data. Secondly, the study focused on radiography graduates from one institution and findings may not be fully applicable to those from other institutions or even to all other healthcare professions. However, the study still provides a foundation to further explore tracer studies to inform both training and policy decisions.

Conclusion

This study has shown that tracer studies can be useful for gathering information that positively impacts on training and policy. The majority of graduate radiographers in this study were satisfied with their work, but made suggestions, such as improving their remuneration and reviewing curricular content, to address the current demands in the work environment. Training institutions are therefore called upon to engage graduates as key

stakeholders in enhancing learning, while government bodies are called upon to utilise the information from graduates to formulate appropriate policies that positively influence healthcare delivery. References 1. Association for African Universities. Regional workshop on tracer studies of past university students, 2001. http://www.aau.org/ (accessed 1 June 2010). 2. Boaduo NAP, Mensah J, Babitseng SM. Tracer study as a paradigm for the enhancement of quality course programme development in higher education institutions in South Africa. Paper presented at the Educational Colloquium, University of North-West, Potchefstroom, South Africa, 20 - 21 August 2009. http://webreg.uzulu. ac.za:8090/itsquery/showQualEnrollment.jsp (accessed 10 October 2011). 3. Schomburg H. Handbook for Graduate Tracer Studies. University of Kassel, Germany: Centre for Research on Higher Education and Work, 2003. 4. Kiguli-Malwadde E, Kijjambu S, Kiguli S, et al. Problem based learning, curriculum development and change process at Faculty of Medicine, Makerere University, Uganda. African Health Sciences 2006;6(2):127-30. 5. Narman A. A tracer study evaluation of the Moshi National Vocational Training Centre (MVTC), Tanzania. Occasional Paper, 1991;4(3), Department of Human and Economic Geography, Göteborg. Göteborg: Göteborg University, 1991. 6. Zembere SN, Chinyama NPM. The University of Malawi Graduate Tracer Study. Blantyre: University of Malawi, 1996. 7. Andrew D, Bankole O, Olatunde A. Labor market prospects of university graduates in Nigeria. Nigeria University System Innovation Project, November 2000. http://siteresources.worldbank.org/NIGERIAEXTN/Resources/ labor_market_univ.pdf (accessed 12 June 2012). 8. Okebukola P. The State of University Education in Nigeria. Abuja, Nigeria: National Universities Commission, 2002. 9. Ugwuonah GE, Omeje KC. Final Report of Tracer Study Research Project on Higher Education and Work. University of Nigeria: Institute for Development Studies,1998. 10. Bennell P, Manyokolo M. A lost generation: Key findings of a tracer survey of secondary school leavers in South Africa. International Journal of Educational Development 1994;14(2):195-206. 11. Bennet N, Dunne E, Carre C. Skills Development in Higher Education and Employment. Buckingham: Society for Research into Higher Education and Open University Press, 2004. 12. Iloeje IC. Graduates’ Employment Survey: A Tracer Study of the Graduates of Faculty of Arts, Agriculture and Education, 1996. http:aau.org/studyprogram/reports/ANYANWU.pdf-194k- (accessed 4 May 2010). 13. Harmening DM. Technologist report overall job satisfaction, 10-ear prospective study examinees’ career patterns. Laboratory Medicines 1996;25(12):773-775. 14. Mubuuke AG, Kiguli-Malwadde E, Businge F, Byanyima R. Factors influencing students’ choices in considering rural radiography careers at Makerere University. Radiography 2010;16(1):56-61. [http://dx.doi.org/10.1016/j. radi.2009.09.003]

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Research The effect of characterisation training on the congruence of standardised patient portrayals I Treadwell,1 DCur, HED; L Schweickerdt-Alker,1 BA (Hons) Drama; D Pretorius,2 MSc (Psych); M D Hugo,3 MOT (Neuropaediatrics) 1

Skills Centre, Faculty of Health Sciences, University of Limpopo (Medunsa Campus), Pretoria, South Africa

Department of Family Medicine, University of the Witwatersrand, Johannesburg, South Africa

Practice of Medicine, Faculty of Health Sciences, University of Limpopo (Medunsa Campus), Pretoria, South Africa

Corresponding author: I Treadwell (ina.treadwell@ul.ac.za)

Background. Incongruence of standardised patient (SP) portrayals is worsened when SPs are given basic scenarios and too little background information on short notice. Consequently, SPs are confronted with questions they find difficult to answer owing to a lack of insight, internalisation and association with the role. Objective. To determine whether training in characterisation enhances the congruence of SP portrayals. Methods. SP encounters were recorded, after which the participating SPs and students reflected on the congruence of the SPs’ performances. The researchers analysed the videorecordings and reflections for incongruent behaviours. The findings were triangulated and themes of incongruency were established. The intervention comprised training of SPs in the creation of subtext (the story behind the story), characterisation, and linking to and making use of emotion memory, with the aim of rectifying the observed incongruent behaviours. Pre-training activities were repeated with Cohort 2 students. Results. Two themes depicting congruence, i.e. internalisation of character and congruence of verbal and non-verbal communication, were identified. Post-training outcomes revealed an improvement in all subthemes. Applicable and real emotions, complementing verbal and non-verbal cues, gestures and appropriate use of voice and facial expression, led to believable/congruent role play and improved communication on various levels. Conclusion. The post-training outcomes showed clear improvement regarding the congruence of SP portrayals. The changes can be contributed to SP training focused on 3D character development by creating subtext, providing basic clinical information, emotion memory, acting skills, managing energy levels, and not focusing on the scenario alone. AJHPE 2014;6(1):56-59. DOI:10.7196/AJHPE.193

Dr Howard Barrows developed the standardised patient (SP) methodology in 1963 and questioned whether SP training is thorough, particularly with regard to history taking. Insufficient training can lead SPs to intellectualise their role playing, rather than become the characters they are playing. In such cases the portrayal of the characters comes across as too memorised, with little transmitted energy and little or no congruence regarding the character.[1]

Congruence of patient portrayals

Congruence is the state of agreement, harmony, conformity, or correspondence, taking all aspects of patient portrayals into consideration.[2] It also involves the practice of personalising perception, critical thinking and creative management of multiple realities as behavioural congruence. It is the concept of being real – not playing a role – and being free from pretence.[3] All of the above are relevant to SP portrayals. It became clear that congruent character development with regard to SPs was necessary to identify and rectify the abovementioned challenges. More specifically, the development of three-dimensional (3D) characters became essential. This was achieved by empowering SPs with adequate information and knowledge, which led to true standardisation of patient portrayals.

Local context and background

At the Medunsa campus of the University of Limpopo, South Africa, SPs have been used for 12 years in the Family Medicine and Primary Healthcare

May 2014, Vol. 6, No. 1 AJHPE

training blocks during summative assessments. To protect the confidentiality of the content, the SPs were issued with written case scenarios immediately prior to the start of an assessment and given approximately 1 hour to prepare. This strategy gave rise to the following problems: • Because of lack of time for proper training, the interpretation of how a patient would normally portray an illness was often stereotyped and/ or unclear. This caused confusion between the student, the SP and the examiner. • The cues and subtexts of case studies were not sufficiently exhaustive/ explicit, and SPs were frequently confronted with questions they had not been prepared for. • Lack of appropriate and timely cues provided to facilitate conversation. • Insufficient time for SPs to internalise the characters and scenarios, resulting in incongruence regarding the verbal and non-verbal communication of the character in relation to the clinical or psychosocial condition. Observing a facial expression while hearing a different emotion manifests as behavioural conflict and interferes with the believability of the portrayal. The abovementioned problems contributed to incongruence of SPs’ portrayal of patients.

Objectives

The aims of the study were to identify behavioural patterns depicting incongruency during SP portrayals, to train SPs in rectifying incongruent

Research portrayals and then to determine the effect of the training.

Methods

A qualitative design was used to gather data on the congruency of SP portrayals through observations and reflections by students, researchers and SPs during objective structured clinical examinations (OSCEs) before and after an SP training session. Medunsa’s Research and Ethics Committee (MREC) approved the study protocol and informed consent was obtained from students and SPs. The convenience student sample comprised two cohorts of 6th-year medical students (N=43) performing their end-of-block OSCEs in Family Medicine. The SP sample included the four junior SPs who participated in both OSCEs.

Reflections prior to training SPs in characterisation SP encounters with Cohort 1 students during OSCE 1 were videorecorded. On completion of the OSCE, students and SPs reflected separately on the incongruence/congruence of the SP performances and videos were analysed by the four researchers. The reflections of the participants were guided by questions and the discussions were audiorecorded.

Data analysis before training

Qualitative content analysis was done according to the steps described by Creswell.[4] The four researchers made summative notes of the videorecorded verbal and non-verbal communication that they regarded as incongruent. Interpretive validity was enhanced by summarising each individual researcher’s documented and interpreted observations and personal experiences. These notes were compared and discussed among the other researchers until consensus was reached on the characteristics of incongruent/congruent SP portrayals observed. The audiotaped focus group discussions of the students and SPs were analysed similarly.

Audiotapes: Data collection and analysis (students)

Corresponding information on characteristics of incongruence obtained from the three sources was grouped in categories, and then organised in themes. Validity and synchronic reliability of the study were achieved by using these multiple sources of information (triangulation) (Fig. 1).[5]

Training of SPs

The intervention comprised a 1-day workshop aimed at transforming the incongruent behaviour of SPs identified during OSCE 1. The training focused on various aspects of creating a believable person behind the patient by finding the subtext relating to the specific scenarios (resulting in 3D character development and energy level management). To enhance their understanding, SPs were given information on the pathology of the disease afflicting the ‘patient’. Training also comprised updating basic acting skills (imagination, listening, emotional expression, use of voice, body movements) to enhance the congruence of their verbal and non-verbal communication. To facilitate SPs to relate to emotions, improvisation exercises were incorporated in the training session.

Post-training analysis

reflections

and

data

A similar content analysis was performed on post-training observations and reflections on SP portrayals at OSCE 2 using the same scenarios with Cohort 2 students.

Results

Reflections before training SPs in characterisation Two themes of congruence and characteristics of congruent behaviours emerged from the data obtained prior to the training of SPs (Table 1). Theme 1 (pre-training). The SPs experienced problems in internalising the patient’s character. Student participants’ observations are summarised as SPs being robotic, hesitant and inconsistent, appearing bored and tired:

Audiotapes: Data collection and analysis (SPs)

Results compared and interpreted Fig. 1. Triangulation of data (SPs = standardised patients).

Videotapes: Data collection and analysis (researchers)

‘ He’s not answering your question … he has a fixed answer. Give him a context of who his patient is … ’ ‘ … it was very robotic but I understand why because they are given a set number of parameters that we are supposed to elicit … ’ ‘ … only a small portion of patients are going to be hesitant like that … ’ SPs reflected that they feared self-expression, were inconsistent and became tired: ‘I faked emotions and that made me tired.’ The researchers observed that the SPs lacked confidence, were inconsistent and struggled to concentrate. Theme 2 (pre-training). The SPs’ portrayals lacked congruence of verbal and non-verbal communication at times. Student participants observed the following incongruencies: ‘ ... the confusion was the body language … he looked “cheery” ... he said he was concerned … but he didn’t show it … ’ ‘ … he didn’t look like it (fears) bothered him …’ SPs acknowledged that they forgot to show symptoms: ‘ … I forgot to show the emotion of pain.’ The researchers found the facial expressions inadequate.

Reflections following training

Observations of the SPs’ portrayals in OSCE 2 reflected improvement regarding the characteristics of congruence (Table 2). Theme 1 (post-training). Problems in internalising the patient’s character. Students reflected that SPs were believable and trustworthy: ‘ … very real … sincere … like a real patient … believable.’ ‘ … she was staying in her role … giving what you were asking for … did not offer information … until a person comes and explores … that’s what people would do … ’ SPs reflected that they understood the role, felt confident and could pace their energy: ‘ … we know you said we must go there and do whatever we were taught during the workshop … then we did exactly that so the doctors (assessors) were so impressed.’ ‘ ... like in the past I was trying to force those fake emotions. I was really getting tired … today from start to finish my energy levels were so high.’

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Research

Table 1. Themes of congruence and characteristics of incongruent behaviours before training Characteristics as analysed/reflected Theme

Students (n=22)

Standardised patients (n=4)

Researchers (n=4)

Internalisation of character

Robotic, not internalising

Fear of self-expression

Lack of confidence

Hesitant, inconsistent

Inconsistent

Appeared bored/energy levels low

Faked emotions

Varied energy levels, struggling to maintain concentration

Not in agreement

Forgot to show symptoms

Poor facial expression

Congruence of verbal and non-verbal communication

Table 2. Themes of congruence and characteristics of congruent behaviours post-training Characteristics as analysed/reflected Theme

Students (n=21)

Standardised patients (n=4)

Researchers (n=4)

Internalisation of character

Believable

Understood the role

Information well managed

Congruence of verbal and nonverbal communication

Felt safe with the patient

Increase of self-confidence

Consistent

Standardised patients did not become tired

Increased energy levels, could pace the energy flow

Energy levels improved and maintained

Symptoms made sense, emotional reactions complemented verbal cues

Could give real emotions

Gestures appropriate, change of voice, applicable emotions expressed

The researchers observed that the SPs managed the information well and their portrayals were consistent. Their energy levels improved and were maintained. Theme 2 (post-training). Incongruence of verbal and non-verbal communication. Students observed that the symptoms portrayed made sense and that the emotional reactions complemented the verbal cues: ‘ … whenever she talked about a hysterectomy she’d take a deep breath … and then talk about it … she really doesn’t want the hysterectomy because [of] her ideas behind it … ’ ‘ … her voice tone changed when she spoke … her body and voice were corresponding … you could see that she was really worried … ’ The SPs felt they were able to portray real emotions: ‘ … what really helped me to show my emotions was the advice that you gave us from the workshop that I have to think of something that makes me like worry so that I need not fake my emotion … ’ ‘ … before the workshop I was constantly smiling, you know even if I had a problem. Today I played a very sad patient … ’ The researchers found the SPs’ gestures appropriate, reflecting the change of voice and expressing emotions were applicable. An unexpected finding was that examiner manipulation of the context and unclear scenario outcomes pose additional threats to congruence: ‘The assessor expects me to do what he wants me to do and that’s a bit difficult … he stopped the assessment and he wants to implement his thoughts on you … you must be consistent … ’

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Study limitations

The insufficient 1-hour SP preparation time prior to OSCE 1, as well as the repeat of the simulations 6 weeks later, may have had an influence on the improvement in SP performance and character portrayal in OSCE 2.

Discussion

The effect of training was measured by comparing post- with pre-training outcomes relating to characteristics of congruence, as reflected in the corresponding lines in Tables 1 and 2. Incongruent behaviours changed to congruent behaviours: • SPs who lacked confidence and acted robotically became believable and managed the role well owing to better understanding. • Hesitant and inconsistent behaviours changed to consistent portrayals executed with confidence. • Low energy levels and problems with concentration changed to increased and maintained energy levels. Having to remember details regarding the scenario will inevitably hamper the flow of communication and affect congruence. SPs should be trained to focus with concentration and energy during the consultation and not try to remember the case scenario. They will then be able to focus on the student and interact spontaneously as the communication/consultation progresses. [6] As far as possible, SP encounters must be true and not different to the experience of a real patient.[7] For SPs to be more congruent, they need to

Research know and give life to the person behind the patient. Portraying a patient is therefore more than repeating a given case scenario; it is about penetrating patients’ psyches, i.e. their emotional and psychological make-up. At the very least, SPs need to understand the needs, expectations and fears of a patient, as well as the biopsychosocial implications of their condition, to portray a congruent and believable patient. This should be explicitly defined in training materials.[6,7] Subtext includes unspoken thoughts and motives of characters (what they really think and believe) and adds a third dimension to the character in the scenario. SPs should be able to portray their symptoms with real emotions, incorporating hidden fears, hopes, beliefs and reactions to interventions. Subtext therefore enables SPs to supply additional circumstances to the character’s background and encourages them to ‘flesh out’ the role.[8,9] What happens beneath the surface of dialogue is what makes the performance exciting.[10] Incongruence of verbal and non-verbal communication changed to revealing real emotions that complement verbal cues, appropriate gestures and voice use, which led to improved communication on various levels. Once the subtext, which focuses on gesture, intonation, and expression, has been defined and the SPs can adopt the patient’s character, their non-verbal signs should become congruent with those of the character. Consequently, the student will be able to ‘hear’ what the SP is not telling them, but what has been ‘shown’ through non-verbal communication. This will keep the energy flowing and the consultation alive and true to a real patient encounter in healthcare. Non-verbal modes of experience such as bodily responses are factors that enable an observer to become more aware of the unconscious affective component of emotional resonance and provide information enabling further cognitive processing.[11] Awareness of bodily responses should therefore be facilitated as non-verbal aspects of experience. This enables the SP to portray a role as alive and real, which makes it effective.[9] SPs’ spontaneity will be enhanced if they are able to identify with their own inner feelings and have the courage to allow these real feelings to manifest naturally. This will result in a more congruent character.[6] For example: pain is an internal physical sensation, accompanied by an emotional response made known in an external manifestation. It could entail the inability to move normally, the experience of body tension, the protection of the location where the pain is most intense, facial expressions, vocalisations, manner of speaking, tone, etc. Only a suitably trained SP can remind the student that handling an affected limb carelessly worsens the pain.[9] Although this study examined the effect of training on congruence, examiner manipulation during an assessment poses a threat to standardised, consistent role play – important for creating fair and equal circumstances

for examinees.[12] SPs should be trained to portray ‘the same patient in such a consistent way that each medical student will be presented with the same challenge every time’.[13]

Conclusion

A congruent portrayal of a patient requires more than receiving a written case scenario. Specific elements are needed for SPs to communicate verbally and non-verbally to the extent that a patient role can become a live experience, where communication is more ‘real’, alive and interdependent.[13] Incongruent performances of SPs prior to focused training can be described as portraying: • unbelievable characters that fear self-expression and lack confidence and energy owing to poor internalisation of the character • non-agreeable verbal and non-verbal communication. The post-outcome training of characterisation showed a clear improvement in the congruence of SP portrayals. The changes can be contributed to the SP training that focused on subtext creation, 3D character development, energy level management, connection with their own emotions, their acting skills as well as the basic clinical information, and not only on the information given in the patient scenario. Training also contributed to increased confidence levels with regard to self-expression. It can be assumed that when SPs are used for role playing in clinical scenarios during examinations, authenticity is of paramount importance.[1] For SPs’ portrayals to remain congruent, continuous training is essential as scenarios and characters change.

References 1. Lewis K, Washington G. Giants in SP education: The legacy of Howard Barrows. Newsletter for the Association of Standardized Patient Educators 2011;10(2):7-9. http://www.aspeducators.org/files/pdfs/pdf1306854670 (accessed 27 May 2011). 2. Online Dictionary. http://dictionary.reference.com/ (accessed 1 August 2012). 3. Cornelius-White JHD. Congruence: An integrative five-dimension model. PCEP Journal 2007;6(4):230-237. [http://dx.doi.org/10.1080/14779757.2007.9688444] 4. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Approaches. 2nd ed. Thousand Oaks, CA: Sage Publications Inc, 2003:191-195. 5. Struwig FW, Stead GB. Planning, Designing and Reporting Research. Cape Town: Pearson Education, 2001:134. 6. Wallace P. Coaching Standardized Patients for Use in the Assessment of Clinical Competence. New York: Springer Publishing Company, 2006:79,94. 7. Monaghan MS, Jones RM, Schneider EF, et al. Using standardized patients to teach physical assessment skills to pharmacists. Am J Pharm Educ 1997;61:266-271. 8. McGaw C, Stilson KL, Clark LD. Acting is Believing.10th ed. Boston, USA: Wadsworth Cengage Learning, 2009:162. 9. Brodzinski E. Theatre in Health and Care. Houndmills, UK: Palgrave/Macmillan, 2010:136-137,146. [http:// dx.doi.org/10.1057/9780230293496] 10. Beck A. Radio drama: Directing, acting, technical, learning & teaching, researching, styles, genres. http://www. savoyhill.co.uk/technique/subtext.html (accessed 21 November 2011). 11. Tagar Y. Fundamentals of Psychophonetic: The Literacy of Experience – the Basic Modes of Non-verbal Communication and Their Applications. Cape Town: Persephone Institute, 2006. 12. Perera J, Perera J, Abdullah J, et al. Training simulated patients: Evaluation of a training approach using self-assessment and peer/tutor feedback to improve performance. BMC Med Educ. 2009;9:37. http://www. biomedcentral.com/1472-6920/9/37 (accessed 21 November 2011). 13. Pretorius D, Van Rooyen M, Reinbrech-Schütte A. Patient-Centred Communication and Counselling – Principles and Practice. Cape Town: Juta & Company Ltd, 2010:72.

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Research Continuous professional training of medical laboratory scientists in Benin City, Nigeria B H Oladeinde,1AIMLS, MSc; R Omoregie,2 MSc, MPhil; I Odia,3AIMLS; E O Osakue,4 AIMLS, BMLS 1

Department of Medical Microbiology, College of Health Sciences, Igbinedion University, Okada, Edo State, Nigeria

School of Medical Laboratory Sciences, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Institute of Lassa Fever Research and Control, Irrua Specialist Hospital, Irrua, Edo State, Nigeria

Department of Pathology, Igbinedion University Teaching Hospital, Okada, Edo State, Nigeria

Corresponding author: B H Oladeinde (bamenzy@yahoo.com)

Background. Training and re-training of healthcare workers is pivotal to improved service delivery. Objective. To determine the proportion of practising medical laboratory scientists with in-service training in Benin City, Nigeria and areas covered by these programmes. Methods. Medical laboratory scientists from Benin City (N=127) (public (n=79) and private (n=48) sectors) were recruited for this study. A detailed questionnaire was used to obtain relevant information from all enlisted participants. Results. Eighty-four (66.1%) of all medical laboratory scientist volunteers (N=127) reported to have attended an in-service training programme. This was significantly associated with gender (male v. female: 80.9% v. 58.8%; odds ratio (OR) 6.071; 95% confidence interval (CI) 2.510 - 14.685; p<0.0001). Only 9/84 (10.7%) participants reported to have had at least one in-service training session during the last 12 months. Attendance was significantly affected by qualification (p=0.029), area of specialisation (p=0.003) and affiliation (p=0.005). Irrespective of affiliation, self-sponsorship of in-service training programmes was most frequently reported by study participants. Training received by respondents was mainly in instrumentation and diagnostic techniques. Conclusion. Attendance of in-service training programmes during the last 12 months was poor. Training programmes were mostly funded by participants. Regular training of medical laboratory scientists by the relevant authorities and agencies is advocated. AJHPE 2014;6(1):60-63. DOI:10.7196/AJHPE.268

Against the backdrop of current emerging and re-emerging diseases, there is a need for accurate and prompt clinical and laboratory diagnosis. The recognition of new infectious agents, the global emergence of antimicrobial resistance and the potential for acts of bioterrorism stress the need for the continuous improvement of laboratory personnelâ&#x20AC;&#x2122;s knowledge. Laboratory medicine is pivotal to the effective management of disease, playing a role in 60 - 70% of decisions related to hospital admission, prescribed medication and discharge of patients.[1] This dependence on laboratory data places the medical laboratory scientist in a prime position with regard to the management and care of patients. One of the major challenges for improving healthcare programmes in sub-Saharan Africa is the lack of quality laboratory services, mainly due to the limited availability of well-trained technical and managerial laboratory personnel.[2] Critical to achieving the United Nations Millennium Development Goals is the improvement of healthcare workersâ&#x20AC;&#x2122; performance.[3] Continued professional development is generally understood to be crucial for the development and improvement of the quality of healthcare delivery services.[4] Training of healthcare workers is an important motivating factor, and is also associated with improved performance of clinical procedures.[5,6] In-service training is important for better performance and could either employ an on-site or off-site training module.[7] It is recognised as a key means by which staff are provided with the necessary knowledge and skill to improve overall institutional performance and achieve the objectives of the organisation.[8] In-service

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training is expected to be conducted regularly and to involve different categories of workers of an organisation so that their skills contribute to the attainment of the organisational goals or objectives.[8] Although management experts and the Nigerian government have identified the importance of training and development in various white papers, these goals of the public service have mostly not been achieved.[9] Findings from a Nigerian study involving healthcare workers in nine public primary healthcare centres in a local government area showed that none of them had received in-service training during the 2 years before the study.[10] The situation is unlikely to be any different in the private sector in Nigeria. While medical laboratory scientists in Nigeria play an important role in qualitative healthcare delivery, little is known about the extent, type and focus areas of their in-service training. The present study aimed to determine the proportion of medical laboratory scientists with in-service training in Benin City, Nigeria, and in the areas covered by such training programmes.

Methods

Study population

Practising medical laboratory scientists (N=127) (42 males and 85 females) were recruited for this study. Seventy-nine participants were from the public sector and the remaining 48 from the private sector, all of them having >1 year post-qualification work experience. A detailed questionnaire (Appendix 1) was used to obtain relevant information from study participants. In-service training included all on- and off-site training received. Informed consent was obtained from all participants prior to completion of the questionnaire.

Research Study approval was obtained from the Edo State Ministry of Health, Benin City, Nigeria.

Statistical analysis

Data were analysed using the chi-squared and odds ratio (OR) tests Graphpad INSTAT. Statistical significance was set at p<0.05.

Results

A total of 84/127 (66.1%) medical laboratory scientists reported to have attended an in-service training programme. Attendance was significantly associated with gender (male v. female: 80.9% v. 58.8%; OR 6.071; 95%

confidence interval (CI) 2.510 - 14.685; p<0.0001). Only 9/84 (10.7%) participants with training reported to have had attended at least one training programme during the 12 months before the study (Table 1). Participants working in public institutions and those with PhD degrees were significantly more likely (p=0.005 and p=0.029, respectively) to have undergone continuous professional training activities. With regard to area of specialisation, medical microbiologists were significantly more likely (p=0.003) to have been engaged in in-service training (Table 2). Self-sponsorship of in-service training programmes was the most prevalent among respondents (Table 3). Training was largely in the area of instrumentation and diagnostic techniques (Table 4).

Table 1. Medical laboratory scientists with in-service training Participants, n

Characteristics

With training, n (%)

95% CI

p-value <0.0001

Ever received training Male

34 (80.9)

6.071

2.510 - 14.685

Female

50 (58.8)

0.165

0.068 - 0.398

Male

3 (2.9)

0.709

0.165 - 3.057

Female

6 (12.0)

1.409

0.327 - 6.070

Received training in last 12 months 0.733

OR = odds ratio; CI = confidence interval.

Table 2. In-service training of medical laboratory scientists with regard to qualification, specialisation and affiliation Participants, n

With training, n (%)

AIMLS

42 (73.6)

6.071

BMLS

21 (50.0)

0.165

MSc

16 (69.5)

PhD

5 (100.0)

Medical microbiology

49 (79.0)

0.709

Chemical pathology

17 (45.9)

1.409

Haematology

16 (72.7)

Histopathology

2 (50.0)

Public institutions

60 (75.9)

3.158

1.468 - 6.792

Private institutions

24 (50.0)

0.317

0.147 - 0.681

Characteristics

p-value

95% CI

Highest qualification 0.029

Area of specialisation 0.003

Affiliation 0.005

OR = odds ratio; CI = confidence interval; AIMLS = Associate of the Institute of Medical Laboratory Science; BMLS = Bachelor of Medical Laboratory Science; MSc = Master of Science; PhD = Doctor of Philosophy.

Table 3. Sponsorship of training programme with regard to affiliation of medical laboratory scientists Training Characteristics

Participants with training, n

Employer, n (%)

Self, n (%)

NGO, n (%)

Affiliation Public institutions

12 (20.0)

48 (80.0)

13 (21.7)

Private institutions

1 (4.2)

22 (92.7)

2 (8.3)

Total

13 (15.5)

70 (83.3)

15 (17.9)

NGO = non-governmental organisation.

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Research

Table 4. Specific areas of training received by medical laboratory scientists Variables

Participants with training, n (%)

Training areas received Instrumentation and diagnostic techniques

34 (40.5)

Laboratory biosafety

13 (15.5)

Internet and computer technology

12 (14.3)

Prevention of hospital-acquired infection

17 (20.2)

Quality assurance

3 (3.6)

Discussion

A major challenge in improving healthcare programmes in sub-Saharan Africa is the lack of quality laboratory services. This is mainly due to the limited availability of well-trained technical and managerial laboratory personnel.[2] The human resources crisis in the healthcare sector in low- and middle-income countries is currently receiving increased global attention.[3] To the authorsâ&#x20AC;&#x2122; knowledge, this is the first study to assess continuous professional training received by practising medical laboratory scientists working in the public and private sectors in Nigeria. Irrespective of area of specialisation, 84 (66.1%) of all medical laboratory scientists participating in this study reported to have received in-service training. However, only 9 (10.7%) participants with such training had attended a course during the 12 months before the study. This is less than the 94.7% reported in a Malawian study among a group of healthcare workers comprising nurses, medical assistants, clinical officers, a laboratory technician and a dental therapist.[4] In recent years, clinical procedures have undergone tremendous changes in that manual handling of samples has gradually given way to an automated approach in many clinical laboratories. Issues relating to risk assessment, procedures for safe use of recombinant DNA technology and transport of infectious materials have also been updated.[11] Although a fair number of respondents (84 (66.1%)) reported to have participated in continuous professional training, the number with such training during the 12 months prior to this survey was poor, which may represent gaps in knowledge of current diagnostic and managerial laboratory techniques. Gender was associated with attendance of in-service training, with male respondents being 3 - 15 times more likely than female respondents to have ever received training. In-service training, depending on whether it employs an on- or off-site training module, can be both expensive and time consuming. Female respondents in this study, apart from their professions, are very likely to be homekeepers and mothers and may therefore, owing to domestic pressures, not readily engage in continuous professional training. However, more females than males had received some form of training in the last 12 months, even though the difference failed to reach statistical significance. This may be related to the current advocacy on women empowerment. In Nigeria, the first generation of medical laboratory scientists was given the professional qualification AIMLT or AIMLS (Associate of the Institute of Medical Laboratory Technology of Nigeria), which is equivalent to a degree. However, current medical laboratory science graduates from various Nigerian universities are awarded the BMLS (Bachelor of Medical

May 2014, Vol. 6, No. 1 AJHPE

Laboratory Science). The development of the medical laboratory science profession in Nigeria has closely followed the same pattern as in the UK. Respondents with BMLS degrees in this study were significantly less likely (p=0.029) to have been engaged in continuous professional training. Professional development opportunities for health workers in Nigeria are limited.[12] Recipients of the BMLS degree (first degree) are unarguably younger professionals, as the awarding of this degree is a recent development in Nigeria. Such respondents are therefore more likely to occupy the lower ranks in laboratories and receive smaller monthly wages. They may therefore not enjoy favourable consideration for selection in training programmes compared with senior colleagues and may also lack the financial ability to undertake such a programme with self-sponsorship. With regard to specialisation, medical microbiologists were significantly more likely (p=0.003) to have been involved in in-service training than other laboratory staff. Infectious diseases account for the majority of deaths in sub-Saharan Africa.[13] Many local and international intervention agencies have focused on diagnosis, prevention and treatment of these diseases, with frequently organised seminars and workshops for healthcare workers and the general public. This emphasis on infectious disease, which falls within the domain of the medical microbiologist, may be responsible for the observed trend in this study. Respondents working in the public sector were observed to be significantly more likely (p=0.005) to have received in-service training than those in the private sector. The public sector is run and funded by the government of Nigeria, which allocates significant annual funds to its operations. Healthcare workers in this sector may therefore enjoy comparatively better funding with regard to workshops and seminars than those in the private sector, which may have accounted for the observations made in this study. Irrespective of affiliation of respondents, involvement of employers in providing sponsorship for training programmes for medical laboratory scientists was the least observed. Self-sponsorship was the most common form of funding for in-service training events reported. This may again explain the poor attendance of training programmes during the 12 months prior to this survey. Despite the recognition of the importance of training by management experts and government, as expressed in white papers on various reforms in Nigeria, the experience of manpower training and development in the Nigerian public service has been one of more ruse and waste.[9] Consequently, many workers in Nigeria, because of limited opportunities for continuous professional development, may have taken their destinies in their own hands to self-fund and engage in personal training to increase their skills. Needs assessment of laboratory staff and laboratory operations is vital for customising training content.[2] The generation of data through disease surveillance and notification systems is critical for appropriate planning, disease-outbreak investigations, emergency preparedness and responses.[14] The trend observed in this study, where management's input in training programmes was minimal, may not translate to improved service delivery, as training sought and obtained may not be tailored to the specific needs of the time, organisation and community. Participants who sponsored their own training programmes may also be unwilling to transfer acquired knowledge to other co-workers to personally remain indispensable in a specific work area. There is a need for increased involvement of management in the articulation and sponsorship of in-service training programmes for medical laboratory scientists.

Research Training was mostly received in the area of instrumentation and diagnostic techniques. The provision of accurate and prompt diagnosis of diseases can be greatly enhanced by increased knowledge in novel diagnostic technologies. For example, the recognition of new infectious agents and the global emergence of antimicrobial resistance make this investment justifiable. Sadly, however, emphasis on such areas as biosafety and quality assurance was low. The safety of laboratory personnel working in diagnostic laboratories is critical in ensuring the continued delivery of laboratory services. Safety training programmes are essential in maintaining safety awareness among laboratory and support staff.[11] Laboratory quality assurance has been summarised as the total process that guarantees the right result, at the right time, on the right specimen, from the right patient, at the right price.[15] This includes procedures beyond the analytical phase of laboratory testing such as collection of appropriate specimens and registration of specimens to clear reporting of results, cutting across preanalytical, analytical, post-analytical and managerial aspects of laboratory organisation. Poor emphasis on training in such critical areas such as quality assurance may undo the impact of other training received and jeopardise quality of test results, as mistakes from analytical procedures alone have been reported to account for a minimal percentage of errors in the clinical laboratory testing process.[16,17]

Conclusion

In summary, 84/127 (66.1%) volunteer medical laboratory scientists reported to have attended an in-service training programme. However, the percentage of volunteers who received training during the 12 months prior to the survey was poor, as was employers’ involvement in training needs of laboratory workers. Adequate assessment of training needs and effective criteria for the selection of training participants are crucial to the success and overall impact of laboratory service delivery. There is a

need for strengthening of laboratory capacity by increasing the emphasis on the training needs of laboratory personnel by the relevant authorities and agencies. Intervention and donor agencies such as the US Presidential Emergency Plan For Aids Relief (PEPFAR), which are involved in the strengthening of laboratory capacity, can provide funds and other training needs to build the capacity of laboratory personnel in Nigeria. Acknowledgement. The authors thank all laboratory scientists who participated in this study. References 1. Oladeinde BH, Omoregie R, Osakue EO, Onifade AA. Evaluation of laboratory request forms for incomplete data at a rural tertiary hospital in Nigeria. N Z J Med Lab Sci 2012;66:39-41. 2. Marinucci F, Medina-Moreno S, Wattleworth M, Paterniti AD, Redfield R. New approach to in-service training of laboratory professionals in sub-Saharan Africa. Int J Biomed Lab Sci 2011;1:1-6. 3. Dieleman M, Gerretsen B, van der Wilt JG. Human resource management interventions to improve health workers’ performance in low and middle income countries: A realist review. Health Res Pol Sys 2009;7:7. [http:// dx.doi.org/10.1186/1478-4505-7-7] 4. Muula AS, Misiri H, Chimalizeni Y, Mpando D, Phiri C, Nyaka A. Access to continued professional education among health workers in Blantyre, Malawi. Afr Health Sci 2004;4(3):182-184. 5. Henderson LN, Tulloch N. Incentives for retaining and motivating health workers in Pacific and Asian countries. Hum Resour Health 2008;6:18 [http://dx.doi.org/10.1186/1478-4491-6-18] 6. Dubois C, Singh D. From staff-mix to skill-mix and beyond: Towards a systemic approach to health workforce management. Hum Resour Health 2009;7:87 [http://dx. doi.org/10.1186/1478-4491-7-87] 7. Oyitso M , Olomukoro CO. Training and retraining Nigerian workers to enhance task performance. Interdiscipl J Contemp Res Bus 2010;4(1):69-77. 8. Danso H, Adu MK, Twum-Ampomah MK, Mprah RK. Evaluation of in-service training for senior staff in a public University in Ghana. J Edu Pract 2012;3(7):6-104. 9. Okotoni O, Erero J. Manpower training and development in the Nigerian public service. AJPAM 2005;16(1):2-13. 10. Mohammed AS, Idowu IE, Kuyinu YA. Structure of primary health care: Lessons from a rural area in South-West Nigeria. Nigerian J Clin Med 2010;3(1):17-24. [http://dx.doi.org/10.4314%2Fnicm.v3il.56576] 11. World Health Organization. Laboratory Biosafety Manual. 3rd ed. Geneva: WHO, 2004. http://www.who.int/csr/ resources/publication/biosafety/BIOSAFETY7/pdf (acessed 12 March 2013). 12. Uneke C, Ogbonna A, Ezeoha A, Oyibo P, Onwe F, Ngwu B. Innovative Health Research Group: The Nigerian health sector and human resource challenges. The Internet J Health 2008;8(1):1-11. [http://dx.doi.org/10.5580/ d5a] 13. Young F, Critchley J, Johnstone LK, Unwin NC. A review of co-morbidity between infectious and chronic disease in sub-Saharan Africa: TB and diabetes mellitus, HIV and metabolic syndrome and the impact of globalization. Globaliz Health 2009;5:9. [http//dx.doi.org/10.1186/1744-8603-5-9] 14. Bawa SB, Olumide EA. The effect of training on the reporting of notifiable diseases among health workers in Yobe State, Nigeria. Niger Postgrad Med J 2005;12(1):1-5. 15. Arora DR. Quality assurance in microbiology. Indian J Med Microbiol 2004; 22(2):81-86. 16. Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem 2002;48:691-698. 17. Plebani M, Carraro P. Mistakes in a stat laboratory: Types and frequency. Clin Chem 1997;43:1348-1351.

Appendix 1. Questionnaire This exercise is aimed at assessing the type and frequency of in-service training received by Medical Laboratory Scientists in Benin City. Your candid opinion on questions asked is highly solicited to guarantee the exactness of our conclusions. Participants and affiliation confidentiality will be maintained. 1. Gender ___________________________________________________ 2. Area of specialisation _____________________________________________________________________________________________________________ 3. Year of first degree in Medical Laboratory Sciences ________________ 4 . Highest academic/professional qualification with date (year) _____________________________________________________________________________ 5. Type of affiliation ☐ Public institution ☐ Private institution 6. Ever had training on your job? ☐ Yes ☐ No 7. Place of training ☐ Within organisation ☐ Outside organisation 8. Specify areas of training received ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ 9. Had training in the last year? ☐ Yes ☐ No 10. Sponsor of training programmes received (please indicate all sponsors of training programme) ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________

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Research Physiotherapy clinical students’ perception of their learning environment: A Nigerian perspective A C Odole,1 PhD; N A Odunaiya,1 MSc; O O Oyewole,2 PhD; O T Ogunmola,1 BPT Physiotherapy Department, College of Medicine, University of Ibadan, Ibadan, Nigeria, and School of Research and Postgraduate Studies, Faculty of Agriculture, Science and Technology,

North West University, Mafikeng Campus, South Africa 2

Physiotherapy Department, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria

Corresponding author: A C Odole (adesola_odole@yahoo.com)

Background. A favourable environment has a positive and significant impact on students’ learning, academic progress and well-being. The present study was undertaken to identify the perceptions of physiotherapy students in their clinical years of their learning environment at the College of Medicine, University of Ibadan, Nigeria. Methods. A focus group discussion involving 12 undergraduate physiotherapy students was used to obtain information about their perception of their learning environment. Six students from two clinical levels of study were recruited through a simple random sampling technique. The focus interview guide was developed based on information obtained from the DREEM questionnaire and literature review. The interviews were analysed using the identified themes from DREEM and grounded theory for emerging subcategories. Results. Five descriptive themes and several subcategories were identified: (i) context of learning (course objectives, student focused/teacher centred, active learning); (ii) context of teachers (knowledgeable teachers, provision of formative assessment, approachable lecturers, cordial teacher-student relationship); (iii) context of students’ perception of their academic skills (understanding the subject); (iv) context of atmosphere (adequacy of facilities, e.g. chairs, classrooms, library, books); and (v) context of social life (religious activities, social functions, school-related social activities). Conclusion. Most students perceived their learning environment as good, especially with regard to student-teacher relationships. Some of the teachers were described as knowledgeable, and as providing formative assessment. However, students perceived their learning as being teacher centred. To facilitate an excellent learning environment, particular attention needs to be paid to availability of physiotherapy textbooks in the college library, sufficient appropriate furniture in classrooms, and provision of a functioning departmental library. The findings from this study may provide insights for teachers who wish to enhance the effectiveness of their teaching and of their students’ learning. AJHPE 2014;6(1):64-68. DOI:10.7196/AJHPE.248

A favourable environment has a positive and significant impact on students’ learning, academic progress and wellbeing.[1] Eliciting students’ perception of the learning environment is a useful basis for modifying it and improving its quality, and provides students with a voice through which they can share their experience in the school.[2] This information, gained through questionnaires, interviews and focus groups, can be used to enhance the strengths and address the weaknesses of the institution. [3] An environment conducive to learning, for example with comfortable learning rooms, a receptive clinical environment and motivated, skilled and approachable teachers, is believed to increase learner motivation, which in turn leads to better engagement in learning and improved performance.[4] Identification of factors that will improve the learning environment, and an understanding of how students learn, will therefore help the teach er to facilitate learning and plan a curriculum to improve learning outcomes.[5] Evaluation of the educational environment comprehensively assesses what is happening and how things are in the school.[1] Interest in the role of the learning environment in undergraduate medical schools has been increasing.[2] Particular attention has been paid to students’ perception of their learning environment in nursing education.[6] In a study carried out in Malaysia, medical students perceived that their teachers were good at communicating with them, and that their teaching helped them to develop

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professional competence. They also considered the overall atmosphere of the school as comfortable, and reported better-than-average social lives.[1] In a study from Australia, health science students perceived that the environment was positive, and also that the teaching was student centred. They reported that the environment had a positive impact on their achievement and success.[7] However, there appears to be no published qualitative study on perceptions of the learning environment among physiotherapy students in Nigeria. It is important to provide empirical information on how these students perceive their learning environment in order to improve their engagement in learning and their performance. This study therefore explored the perceptions of physiotherapy students in their clinical years of their learning environment at the College of Medicine, University of Ibadan, Nigeria, with the intention of using the findings from the study to enhance the strengths and address the weaknesses of the institution, and so improve the learning environment.

Methods

A qualitative methodology was used to investigate the students’ perceptions of their learning environment. The study sought to explore individual student experiences, which are considered valuable for improving understanding of aspects of the experience of the education environment. The study could be described as phenomenological in nature.[8] It has been suggested that a

Research focused discussion is suitable when the informants are involved in more or less the same situation. Using this method, the informants received support to describe their cognitive and evaluative meaning around a theme, i.e. in this context focusing on their views of and thoughts about their learning environment.[9] Before commencement of the study, ethical approval was sought and obtained from the University of Ibadan/University College Hospital Research Ethics Committee. Each student involved signed an informed consent form in which ethical issues were addressed, including guaranteed confidentiality and freedom to withdraw from the study at any time. Statements on confidentiality were included in the informed consent form. Students’ names were not included in the recordings. The focus group discussion involved 12 of a total of 54 undergraduate physiotherapy students (26 at level 400 of study and 28 at level 500 – these are the full clinical years of study at the university). Six students were selected from each level through a simple random sampling technique (fishbowl technique), in which 6 names were picked randomly from a bowl containing the names of the level 400 students and another 6 from a bowl containing the names of the level 500 students. The students whose names were picked were invited to participate in the study. The focus interview guide was developed based on information obtained from the Dundee Ready Education Environment Measure (DREEM) questionnaire[10] and literature review. It was assessed for content validity by five physiotherapy educators at a departmental seminar. The DREEM is a 50-statement, closed-ended questionnaire developed to assess the learning environment of educational establishments.[10] It has been found to have good internal consistency.[10-12] Each of the 50 items falls into 1 of 5 categories: students’ perceptions of learning; students’ perceptions of teachers; students’ academic self-perceptions; students’ perceptions of atmosphere; and students’ social self-perceptions.[7] The focus guide included the five questions listed below. The discussion was conducted in English, the official language of communication/study in Nigeria. Question 1: What are some of your challenges in the learning process? Probe: Is the teaching student centred? Are course objectives provided at the start of the course? Is teaching teacher centred? Is the teaching period put to good use? Does the teaching emphasise the long term more than the short term? Question 2: What can you say about the whole teaching process in physiotherapy? Probe: Are the teachers knowledgeable? (method of teaching, studentteacher relationship, and teachers’ organisation, preparation and feedback). Question 3: What are your views on your learning environment? Probe: How conducive is it to learning? (infrastructure, facilities, library, equipment). Question 4: Does studying physiotherapy have any influence on your social life? How? Probe: Does studying physiotherapy restrict you from, or expose you to social life? Do you have time for other things apart from academic activities? How is your relationship with lecturers and students? How often do you make new friends? Question 5: Is there anything more you would like to share with regard to your learning environment? Probes were used in each question to clarify participants’ responses and elicit more complete responses to the question. The interview focus guide was used to guide the moderator and maintain uniformity in the topic

that was being explored; to obtain more information, further questions were asked and probed by the moderator. We acknowledge that some questions in the focus guide were directional, even though this appears to be a limitation in qualitative studies. Before commencement of this study, many of the students had complained informally about their learning environment to some lecturers. Moreover, a study from Nigeria had reported challenges faced by medical students in the learning process.[13] Experience in our learning environment reveals that students tend to respond better to questions that are directional. In addition, in the Nigerian cultural context, asking a direct question will elicit comprehensive information rather than evasive responses. The focus group discussion was guided by a facilitator (a postgraduate student from the Institute of Child Health, College of Medicine, University of Ibadan) who is knowledgeable and trained in focus group discussion. The participants were encouraged to talk freely and spontaneously. Three discussion sessions were held, the first between male students from both levels of study, the second between female students, and the third with males and females combined. This was done in order to encourage the students to provide fuller information, as we thought that gender could influence their responses – we considered that some intimate issues such as cases of sexual assault on both males and females would be better explored in separate groups. Each session lasted for about 60 minutes. The sessions were audio recorded, and an observer also took notes. The recorded information was transcribed verbatim, and content analysis of the transcripts was carried out by two individuals knowledgeable in qualitative analysis. They transcribed independently and later met to arrive at a consensus.[9] The themes were taken from the DREEM questionnaire, while substantive statements relevant to the question and common descriptive subcategories were identified using the grounded theory approach.[5,9,14] Even though some of the themes have been identified in the literature, we were of the opinion that they may not strictly apply to our cultural context, where elders dominate and whatever they do is supposed to be right, so we still needed to explore the perceptions of the students. However, we felt that we could be guided by established themes from previous studies [1,2,7] Content thematic analysis was used to analyse the information that emerged.

Results and discussion

Five themes identified from the DREEM questionnaire were used in the analysis of the information obtained (Table 1). These are the context of students’ perception of learning, the context of students’ perception of teachers, the context of students’ perception of their own academic skills, the context of students’ perception of their learning environment, and the context of students’ perception of their social life.

Students’ perception of learning

Providing quality learning experiences is the goal and responsibility of all educational programmes, and assures student, faculty and programme success.[15] The aim of this theme was to explore the University of Ibadan undergraduate physiotherapy clinical students’ perception of learning. Three subcategories that emerged from this theme were teacher-centred teaching, optimal use of the lecture period by teachers, and provision of course objectives. We wanted to address students’ views of the teaching activities, such as whether they received course objectives, whether they found that the teaching period was being put to good use, and whether

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Research

Table 1. Themes and description of the responses Category

Theme

Description

Context of learning

Teacher-centred teaching, optimal use of the lecture period by teachers, provision of course objectives

Context of teachers

Knowledgeable teachers, provision of formative assessment, approachable lecturers, cordial teacher-student relationship

Context of students’ perception of their academic skills Understanding the subject, translation of theoretical knowledge to application

Context of atmosphere

Inadequate facilities (chairs, classrooms, library, books)

Context of social life

Religious activities, student-related social activities, social functions

learning was student focused and encouraged active learning, as opposed to a teacher-centered approach. The majority (9) of the participants reported that some lecturers did not utilise their lecture periods adequately. A participant stated: ‘The teaching time isn’t put to good use by some lecturers.’ Another student said: ‘We do not receive learning objectives for some of our courses, and some lecturers do not tell students they will not be around for classes and they keep us waiting, which I think is not helpful to the student.’ Another said: ‘Some of them are still using the old style of lecturing where they just dictate their old lecture notes without updating.’ The learning problems experienced by these students could be explained in terms of the cultural perspective: ‘Elders are always right: they have good reasons for whatever they do, they cannot be wrong and must not be challenged.’ Teachers with this attitude do not see it as their responsibility to give learning objectives to students, nor do they feel they owe students an explanation for being absent or late for lectures. They are often not studentcentred in their teaching, and students perceive their approach as being teacher-centred. In order to enhance learning, students should perceive it as an activity that transcends ordinary teaching. It should be characterised by teachers inspiring, supporting, actively involving and communicating with their students.[16] We propose that the provision of learning objectives to students at the beginning of a course helps them to take responsibility for their learning and provides opportunities for them to develop autonomy by selfdirected learning.[17] Lecturers in the Nigerian context may need to absorb new sets of values that would facilitate students’ learning.

Students’ perception of teachers

The theme was introduced with the purpose of exploring the students’ perception of their teachers. The subcategories that emerged from this theme were the student-teacher relationship, feedback and formative assessment of students, and teachers’ knowledge of taught courses. Teachers facilitate transmission of knowledge, and they constitute part of the learning environment. A knowledgeable, motivated, skilled and approachable teacher is likely to increase learners’ motivation, which in turn leads to better engagement in learning and improved performance.[18] Students’ positive perception of their teachers has been recognised as an important characteristic of effective learning experiences in a previous study.[19] The teacher or facilitator is one of the most powerful variables in the educational environment. His or her actions, attitudes (e.g. evidenced by tone of voice or comments made), enthusiasm, and interest in the subject will affect learners indirectly.[20] A teacher should aim to provide an environment in which learners feel safe to experiment, voice their concerns, identify their lack of

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knowledge, and stretch their limits.[20] Physiotherapy educators should be responsible for teaching physiotherapy students how to provide healthcare safely, efficiently and effectively in potentially multicultural environments. Physical factors can make it difficult for learners and teachers to relax and pay attention. Ensuring adequate breaks and being mindful of the physical environment are part of the teacher’s role.[20] An environment conducive to learning may provide insights for teachers who wish to increase the effectiveness of their teaching and their students’ learning. For example, it may be relatively easy to change how feedback is given to students, to make classroom sessions more interactive, or to ‘check in’ with the class more frequently. It has been suggested that teachers may not be aware of effective and/or innovative strategies used by their colleagues in the same institution. One simple approach to faculty development could be to provide a forum for faculty members to share their ‘best practices’ for teaching.[19] Teachers’ knowledge Half of the participants reported that the lecturers were knowledgeable generally, while others had varied perceptions of their teachers’ knowledge. One participant said: ‘I will say generally that they are knowledgeable, but I can classify our lecturers into two groups. One group is those … who lecture for lecturing’s sake, but the other group are those who lecture you for future purpose, they lecture you so that you can know, so that you can apply it in your practice, they lecture you like they know this thing.’ Another participant said: ‘… based on the confidence with which lecturers answer questions in class, I feel that not all the lecturers are knowledgeable. Some lecturers prove to be more knowledgeable, based on the way they answer the questions and give us stuff.’ We believe that students can assess their teachers’ knowledge of taught courses. They all have the course content and curriculum at the beginning of the session. They are being taught to take responsibility for their learning, and all of them can access information on the internet and from textbooks. The ability of lecturers to give in-depth but comprehensible explanations reassures students that their teachers have good knowledge of the courses that are being taught. Feedback and formative assessment Four of the participants reported that the teachers provided feedback, and 2 participants reported that impromptu tests are given for assessment of learning (formative assessment). A participant said: ‘… 60 - 70% of the lecturers give impromptu tests to assess our knowledge on what they taught us, and if they observe from our scores that we didn’t get the questions right they will still want to revise with us.’ Impromptu tests can be used

Research for formative assessment of students’ learning, whereby the lecturers use test scores to identify areas that need to be made clearer to the students. Students’ scores are not used in the summative assessment; instead, they provide feedback on areas that need more work.

threat of forced disclosure of personal details.[20] Teachers should attempt to get a sense of what students know and can do, as well as their interests and passions, and what each student cares about and wants to do.[24]

Student-teacher relationship An excellent learning environment should include student-teacher interaction, not just teachers imparting knowledge to students.[18] Almost all (10) of the participants reported that most of their lecturers were approachable, and 5 reported that they had a cordial relationship with their teachers. One participant said: ‘The relationship between the teachers and lecturers is cordial.’ Another said: ‘They can talk to you any time, even when you do not understand what they taught you in class, you can walk to their offices and they will re-explain to you without asking any question. Most of them are approachable.’ Another said: ‘The interaction between the lecturers and the students is just like between children and their parents.’ Most of the participants compared their student-teacher relationships with those in other departments in the faculty. A participant said: ‘… relating to other departments, I think it’s good. Most of the lecturers keep open doors; some will even give you their number, so you can give feedback. Some of them extend it to a personal level.’ Most participants reported that some of their lecturers were friends with them on Facebook. In addition, a participant said: ‘The relationship is so cordial, and it encourages a more conducive environment for learning. We do not have to become hypertensive because our lecturer just walked in!’ The students take courses from various departments and faculties in the university in their preclinical levels of study (first to third years), and also share accommodation with students from other departments and faculties. These experiences enabled them to compare student-teacher relationships in the physiotherapy department with those in other departments. The participants’ responses highlight the vital importance of students’ perception of their teachers. They reported that some of the lecturers appeared more knowledgeable than others in terms of how well they were able to explain the content of the courses. Few reported on the provision of feedback. Most of them stated that the teachers were approachable, and they all reported that teacher-student relationships were cordial. Most added that their teachers were friends with them on Facebook, possibly suggesting social interaction between the students and the teachers. According to Stronge et al.,[21] social interactions between teachers and students encourage students to learn and achieve. Such interaction, and the provision of an environment in which students feel free to voice their concerns, identify their lack of knowledge and stretch their limits, will therefore facilitate learning.[4] One study found that teachers do not only teach; they also perform many other non-teaching tasks and functions (e.g. administrator, counsellor and friend).[22] It has been reported that a teacher who spends time interacting socially with students, works directly with them, and demonstrates a sense of fun and willingness to participate in a friendly and personal manner, is considered to be effective.[18] Physiotherapy educators act as role models for students, and therefore need to have highly developed cultural awareness, cultural knowledge, cultural sensitivity and cultural competence.[23] Remembering names and involving learners in setting ground rules are ways in which mutual trust can be built up. Feedback on performance, a vital part of teaching, should be done constructively and with respect for the learner; safety can be compromised through humiliation, harassment, and

This context addressed students’ views of their learning strategies, and problem-solving skills they have developed to prepare themselves for the physiotherapy profession. It has been suggested that there is an intimate relationship between students’ perceptions of the quality of their courses in higher education and the approaches to studying that they adopt in those courses.[25] Most of the participants read to gain more complete understanding rather than just to pass. One student said: ‘Initially when I was in preclinical school, my idea … was just to read and pass, but now I understand better that it is not all about reading and passing but it is about doing and knowing the basis of what you do, which I think is more important.’ The students perceived that what they were being taught in the classroom could be applied in the care of their patients once they were in clinical practice. At the clinical level of their studies, it was apparent that they had achieved higher levels of cognition (application, analysis, synthesis and evaluation) in addition to lower levels of cognition (knowledge and comprehension). Students with a deep approach to learning have the intention of understanding, engaging with, operating within and valuing a question.[26] They are interested in learning for its own sake, wanting to understand ideas for themselves and not because of the marks they will score. The majority of the respondents reported that learning is not all about reading and passing, but about the ability to apply the theory. Cognitive learning, a highly active process largely directed by the individual, involves perceiving the information, interpreting it on the basis of what is already known, and then re-organising the information into new insights or understanding.[27] Cognitive learning theory includes several wellknown perspectives, such as gestalt, information processing, cognitive development, situated cognition and social cognition theory.

Students’ perception of their academic skills

Students’ perception of their learning atmosphere

Student perceptions of a good learning atmosphere encourage deep approaches to studying and influence learning outcomes both directly (perceptions of outcomes) and indirectly (perceptions of approaches to outcomes).[28] This theme addressed our students’ perception of their learning environment (how relaxed the atmosphere is during lectures, whether infrastructure is adequate, whether there are opportunities to use and develop interpersonal skills, availability of recommended books in the library). The question asked was ‘What are your views about your learning environment?’ The majority (10) of the participants reported that it presented many challenges, especially with regard to infrastructure. Participants commonly reported that the chairs in the lecture room were uncomfortable and of poor quality, and there were too few chairs. A participant said: ‘The chairs are bad and it is very difficult sitting on this chair for 2 - 4 hours.’ Another said: ‘We do not have good chairs for learning, we have so many bad chairs and we are just managing and patching.’ Another added: ‘The chairs are not enough, two lectures cannot be held simultaneously, for example the 400 and 500 level students cannot hold classes simultaneously.’ Apart from the inadequate chairs, a participant also said: ‘The classrooms are so clumsy, there are not enough spaces for lectures, some of the time we use rooms meant for practical classes for lectures.’

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Research In addition to complaints about the chairs and the classrooms, the majority (75%) of the participants reported that the department did not have a functioning library to promote additional reading. A typical response was: ‘There are no facilities for further reading like a library.’ Elaborating, one participant said: ‘We do not have physiotherapy books, even in the medical library in the college, so there is nothing to fall back on after getting stuff in class.’ A participant also emphasised the scarcity of physiotherapy textbooks in the bookshop: ‘I went around the college bookshop and the only books I could see were more of medical books, dental books and nursing books, you can count the number of physiotherapy books. I was very annoyed.’ The learning environment is not limited to student-teacher interaction, teaching and learning activities, but also includes good physical structures and facilities.[29] These include good (and sufficient) chairs, sufficient classrooms suitable for their purpose, a well-equipped library and access to relevant books, all of which are important for optimal learning outcome.

Students’ social life

We asked the question ‘Does physiotherapy restrict or expose you to social life?’ This question could be regarded as a leading one; however, in our context students respond better when they are directed. The intention was to capture information on how the course has impacted on participants' social life. While one respondent felt that ‘Social life depends on the individual’, most (8) of the participants reported that their social lives involved schoolrelated social activities (quiz competitions, sports, students’ carnivals), and attending fellowship (i.e. religious activities), and social functions such as weddings and birthday parties. One participant said: ‘Social life for me is school.’ Almost all the participants (n=11) reported that their physiotherapy studies did not hinder their participation in social activities, one stating: ‘Physiotherapy does not restrict my social life, you just need to plan your time well.’ Another went into more detail: ‘Physiotherapy permits us to socialise like during the hall week, physiotherapy allows us to go out for dinners.’ A very enthusiastic participant said: ‘One thing physiotherapy is known for is social gathering, we do it to the peak. I give it to them thumbs up!’ A social learning environment equips students with the tools necessary to collaborate with teachers and peers and participate in activities both inside the classroom and beyond the walls of the school. A safe social networking/ learning environment can extend the relationship between students to allow continued dialogue and collaboration after school hours.[30] Most of the participants concluded that their social life was good, and that physiotherapy did not restrict their social life.

Conclusion

This qualitative study, which appears to be the first on physiotherapy students’ perception of their learning environment in Nigeria, indicated that most students perceived their learning environment as good, especially with regard to student-teacher relationships, although fewer described their teachers as knowledgeable and as providing formative assessment. Most also felt that their social lives were not restricted by studying physiotherapy. However, students perceived their learning environment to be inadequate in terms of facilities such as the library, chairs and classrooms. They also reported that some teachers did not make good use of lecture periods. The findings highlight some of the strengths and weaknesses of the learning environment at the College of Medicine, University of Ibadan, as

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perceived by physiotherapy students. The strengths could be enhanced and the weaknesses addressed in order to improve the situation. The results of the study cannot be generalised to all physiotherapy institutions in Nigeria, as we focused on one institution (the University of Ibadan), but further studies could be carried out elsewhere. Furthermore, our students’ perception of their learning environment could be evaluated on an ongoing basis, as part of quality assurance. Finally, the findings may provide insights for teachers who wish to enhance the effectiveness of their teaching and their students’ learning. We recommend that workshops on biomedical education be organised. In particular, these workshops should address cultural issues that impact negatively on students’ learning. References 1. Arzuman H, Yusoff MSB, Chit SP. Big Sib students’ perceptions of the educational environment at the School of Medical Sciences, Universiti Sains Malaysia, using Dundee Ready Educational Environment Measure (DREEM) inventory. Malays J Med Sci 2010;17(3):40-47. 2. Prayoonwong T, Nimnuan C. Dental students’ perceptions of learning environment. South‐East Asian Journal of Medical Education 2010;49(1):49-54. 3. Roff S. The Dundee Ready Educational Measurement (DREEM) – a generic instrument for measuring students’ perceptions of undergraduate health professions curricula. Med Teach 2005;27(4):322-325. [http://dx.doi. org/10.1080/01421590500151054] 4. Hutchinson L. ABC of learning and teaching: educational environment. BMJ 2003;326(7393):810-812. [http:// dx.doi.org/10.1136/bmj.326.7393.810] 5. Pimparyon P, Roff S, McAleer S, Poonchai, B, Pemba S. Educational environment, student approaches to learning and academic achievement in a Thai nursing school. Med Teach 2000;22(4):359-364. 6. Said NM, Rogayah J, Hafizah A. A study of learning environments in the Kulliyyah (Faculty) of Nursing, International Islamic University, Malaysia. Malays J Med Sci 2009;16(4):15-24. 7. Brown T, Williams B, Lynch M. The Australian DREEM: Evaluating student perceptions of academic learning environments within eight health science courses. International Journal of Medical Education 2011;2(2):94-101. [http://dx.doi.org/10.5116/ijme.4e66.1b37] 8. Clouder L, Toms J. Impact of oral assessment on physiotherapy students’ learning in practice. Physiother Theory Pract 2008;24(1):29-42 [http://dx.doi.org/10.1080/09593980701378157] 9. Borglin G, Fagerström C. Nursing students’ understanding of critical thinking and appraisal and academic writing: A descriptive, qualitative study. Nurse Educ Pract 2012;12(6):356-360. [http://dx.doi.org/10.1016/j. nepr.2012.04.009] 10. de Oliveira Filho GR, Viera JE, Schonhorst L. Psychometric properties of the Dundee Ready Educational Environment Measure (DREEM) applied to medical residents. Med Teach 2005;27(4):343-347. [http://dx.doi. org/10.1080/01421590500046387] 11. Mayya S, Roff S. Students’ perceptions of educational environment: A comparison of academic achievers and under-achievers at Kasturba Medical College, India. Educ Health 2004;17(3):280-291. [http://dx.doi. org/10.1080/13576280400002445] 12. Roff S, McAleer S, Harden RM, et al. Development and validation of the Dundee Ready Education Environment Measure (DREEM). Med Teach 1997;19(4):295-299. [http://dx.doi.org/10.3109/01421599709034208] 13. Anyaehie USB, Nwobodo E, Oze G, et al. Medical students’ evaluation of physiology learning environments in two Nigerian medical schools. Adv Physiol Educ 2011;35(2):146-148. [http://dx.doi.org/10.1152/advan.00106.2010] 14. Maeno T, Takayashiki A, Anme T, Tohno E, Maeno T, Hara A. Japanese students’ perception of their learning from an inter professional education program: A qualitative study. Int J Med Educ 2013;4(1):9-17. [http://dx.doi. org/10.5116/ijme.50e5.e19a] 15. Somenarain L, Akkaraju S, Gharbaran R. Student perceptions and learning outcomes in asynchronous and synchronous online learning environments in a biology course. J Online Learn Teach 2010;6(2):353-356. 16. Kernan WN, Hershman W, Alper EJ, et al. Disagreement between students and preceptors regarding the value of teaching behaviors for ambulatory care settings. Teach Learn Med 2008;20(2):143-150. [http://dx.doi. org/10.1080/10401330801991667] 17. Gummesson C, Nordmark E. Self-reﬂections in an online course – reﬂecting learning strategies? Adv Physiother 2012;14(2):87-93. [http://dx.doi.org/10.3109/14038196.2012.671848] 18. Rubio MC. Effective teachers – professional and personal skills. ENSAYOS. Revista de la Facultad de Educación de Albacete 2009;24(1):35-46. 19. Victoroff KZ, Hogan S. Students’ perceptions of effective learning experiences in dental school: A qualitative study using a critical incident technique. J Dent Educ 2006;70(2):124-132. 20. Hutchinson L. ABC of learning and teaching: Educational environment. In: Cantillon P, Hutchinson L, Wood D, eds. BMJ ABC of Learning and Teaching in Medicine. London: BMJ Publishing Group, 2003. 21. Stronge JH, Tucker PD, Hindman JL. Handbook for Qualities of Effective Teachers. Alexandria, VA: Association for Supervision and Curriculum Development, 2004. 22. Ngoh MS, Wong I, Wong A. A qualitative study of perceptions of student teachers towards teaching 2012. http/ www.conference.niesg/paperycovert/as00616.pdf (accessed 5 October 2012). 23. Bialocerkowski A, Wells C, Grimmer-Somers K. Teaching physiotherapy skills in culturally-diverse classes. BMC Med Educ 2011;11(1):34. [http://dx.doi.org/10.1186/1472-6920-11-34] 24. Bransford JD, Brown AL, Cocking RR. How People Learn: Brain, Mind, Experience, and School. Expanded edition. Washington, DC: National Academy Press, 2000. 25. Richardson JTE. Students’ perceptions of academic quality and approaches to studying in distance education. Br Educ Res J 2005;31(1):7-27. [http://dx.doi.org/10.1080/0141192052000310001] 26. McKimm J. Learning theories. 2002. http://www.faculty.londondeanery.ac.uk/e-learning/setting-learningobjectives/Toolbox%20-%20%20Learning%20theories.pdf (accessed 23 February 2012). 27. Hammond L, Austin K, Suzanne O, Rosso J. How people learn: Introduction to learning theories. 2001. www. stanford.edu/class/ed269/hplintrochapter.pdf (accessed 23 February 2012). 28. Lizzio A, Wilson K, Simons R. University students’ perceptions of the learning environment and academic outcomes: Implications for theory and practice. Studies in Higher Education 2002;27(1):27-52. [http://dx.doi. org/10.1080/03075070120099359] 29. Demiroren M, Palaoglu O, Kemahli S, Ozyurda F, Ayhan IH. Perceptions of students in different phases of medical education of educational environment: Ankara University Faculty of Medicine. Med Educ Online 2008;13(1):8. [http://dx.doi.org/10.3885/meo.2008.Res00267] 30. Braungart M, Braungart R. 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Abstracts Sixth National Conference of the South African Association of Health Educationalists (SAAHE): ‘Information to Transformation’, Umhlanga, 27 - 29 June 2013 AJHPE 2014;6(1):69-113. DOI:10.7196/AJHPE.419

ORAL AND POSTER PRESENTATIONS Rural electives: Providing transformative learning opportunities and influencing choice of career: The Stellenbosch University experience B Willems* *bartwillemsza@gmail.com Background. Rural background and longitudinal rural clerkships for medical students including training at rural medical schools are established predictors for rural practice. Considering that less than a third of all South African medical students originate from rural areas and are educated at urban universities, additional strategies are necessary to encourage rural career choices. Objective. This study explores the benefits of a 1-month rural elective in influencing further rural practice and is funded by the Stellenbosch University Rural Medical Education Partnership Initiative. Method. This qualitative study evaluated rural elective students’ learning experiences and possible influences on future career choice. Online anonymised surveys and feedback from focus group discussions were analysed to identify recurring themes. Results. Students described the rural elective as an enriching experience and a positive opportunity facilitating exposure to the context in which they will ultimately work. Adapting to environments with limited resources and populations with varying cultural backgrounds were embraced and valued by students. In addition, learning opportunities for community engagement and patient-centred care were seen to inspire students to return to rural areas. Conclusion. Rural electives provide transformative learning experiences that could influence urban-educated medical students’ choice of working in rural areas. Further investigation of this model is recommended. Innovative medical education models offering shorter periods of rural exposure may serve to enhance rural recruitment in South Africa. A qualitative exploratory study: Using medical students’ experiences to review the role of a rural clinical attachment in KwaZulu-Natal L Campbell* *laura@hss.co.za Background. There are challenges when considering that the main role of a rural clinical attachment for medical students is to encourage students to return after graduation to practise in rural areas; such a view may lead to relative neglect of other potential valuable roles of rural exposure. Objective. This paper draws on the ‘Force Field Model of Teacher Identity’ to describe medical students` experiences, illustrate the complexity of factors interacting during rural exposure, caution that experiences cannot be predicted and highlight the positive role of a rural clinical attachment.

Method. The study setting was a district hospital in rural KwaZulu-Natal and participants were four final-year medical students who had completed a compulsory attachment during their Family Medicine rotation. Data were collected using photo-elicitation and analysed using the Force Field Model. Results. Participants felt that, overall, it was a positive the experience. The effect of biography and contextual forces were not as strong as could be expected. Institutional forces were important and programmatic forces tended to have a negative effect on experiences. Participants particularly enjoyed being acknowledged and gained empathy around the difficult tasks of doctors. Conclusion. The potential positive role of a clinical attachment may go beyond attracting students to practise in rural areas. Experiences could be beneficial, irrespective of where the students select for future practice. There is a need for review of rural attachment curriculum and pedagogy. Caution should be used when screening medical students for suitability to work in rural areas prior to rural exposure. Experiential learning outside the comfort zone: Taking medical students to downtown Durban N Prose,* P N Diab, M Matthews *diabp@ukzn.ac.za Background. The ability to communicate across cultures requires a combination of knowledge, skills, and attitude. Our current medical school curriculum includes innovative methods of teaching communicative knowledge and skills. The challenge is how to teach students how to interact with empathy in the multicultural society that awaits them. Objective. Various methods of teaching empathy have been utilised worldwide but this particular presentation reflects on an experiential learning activity that yielded positive results. Method. A diverse group of pre-clinical students volunteered to take part in an experiential learning outing in the Warwick Triangle area of Durban. A tour operator specialising in cross-cultural tours for business groups offered to facilitate the experience free of charge. Students consented to the tour and permission was granted from the medical school dean for the opportunity. At the muthi market, students were divided into smaller groups and each group was asked to obtain a specific herbal medication and learn of its uses. The students also participated in a tour of the Juma Masjid mosque. Several days later, the students met together again to debrief the experience. Results. Upon reflecting, students revealed that they were able to appreciate and gain a wealth of cultural knowledge and that they had begun to develop an attitude of curiosity about cultures other than their own. They were also able to learn from challenges that were encountered within a safe environment. The overall impact on the students appeared to be very powerful. A number of students expressed appreciation at being in a

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Abstracts multicultural group, having a shared experience, and engaging in an open and respectful discussion about similarities and differences. Conclusion. We believe that our students need to be involved in experiential learning that encourages them to examine their attitudes, and to develop curiosity about and respect for patients coming from cultures other than their own. We describe an innovative, experiential approach to learning, and suggest ways in which learning experiences of this type can be integrated into the MB ChB programme. Person-centred community-based interprofessional care: A strategic opportunity for service-learning to reform health professions education S Snyman,* C Goliath, H Boshoff, N Smit, P Khati *ssnyman@sun.ac.za Background. A Lancet commission recently stated that person-centred and community-based care are key in reaching health equity. Their recommendations to address health inequity have far-reaching implications for health professions education. It is the position of this paper that most of these recommendations could be addressed by an interprofessional servicelearning approach. Objective. The aim of this study was to determine, before and after a interprofessional service-learning experience, how perceptions of students changed regarding (i) the roles of other health professions; and (ii) their approach to patients, clients and the community. Method. The research followed a phenomenological school of thought in an interpretative paradigm with a qualitative-inductive approach. In-depth focus group interviews were conducted with 64 students before each rotation, directly afterwards, and a year later. Interviews were conducted with 10 clients and six community-based carers before the students became involved and a year later. Results. Initially students expressed scepticism about teamwork with mostly negative perceptions about other health professions. They primarily practised a biomedical model of care with little understanding of the psycho-socialspiritual factors influencing health. Clients and community-based carers felt disempowered, inferior and demotivated. Directly after each rotation and a year later, students reported appreciation for the different professions and a positive attitude towards interprofessional bio-psycho-social-spiritual person-centred care. However, students experienced difficulty ensuring continuity of care due to the short duration of rotations. Clients and community-based carers felt better equipped to take responsibility in promoting health, self-care and parenting. Conclusion. Service-learning can play a valuable role in facilitating healthy interprofessional teamwork in person-centred and community-based care. The challenge for the service-learning fraternity is to promote this pedagogy among health professions educationalists as a solution to equip students to contribute towards equity in health in the 21st century. From mixed expectations to change in professional practice: Graduate perspectives of a rural clinical school experience S van Schalkwyk,* J Bezuidenhout, H Conradie, N Kok, B van Heerden, M de Villiers *scvs@sun.ac.za Background. In 2011, the first cohort of eight medical students spent their entire final year at the Ukwanda Rural Clinical School (RCS). As

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part of a 5-year, longitudinal evaluative research project to determine the impact of its implementation, a baseline study was conducted during the initial year that highlighted the potential of the RCS intervention to offer transformative learning experiences for the students. Objective. The aim in the second year of the study was to track the 2011 cohort into their internship to discern the extent to which their RCS year still influenced their thinking and practice. Method. Focus group discussions had been held before this group entered the RCS. Interviews were then conducted with them during 2011. In 2012, another set of in-depth interviews took place with the eight interns during the latter part of their first year of internship. In addition, a supervising clinician of each intern was interviewed telephonically. The transcripts were subjected to thematic content analysis. Drawing on these four data sets, we used Kirkpatrick’s model for evaluating educational outcomes to develop a matrix of the participants’ views, highlighting any shifts that occurred over time. Results. It was evident from the analysis that the students’ initial uncertainties around the RCS were allayed during the year’s exposure (Level 2a) and they felt confident that their clinical skills had grown (Level 2b). As interns they described how this confidence manifested in their behaviour (Level 3) and their professional practice (Level 4a). This was often confirmed by the intern supervisor. Conclusion. Research claims made regarding the potential of an extended rural clinical experience to effect transformative learning are further confirmed by this study. Several questions, however, remain unanswered, including the extent to which patient care (Level 4b) is ultimately enhanced – the focus of the next phase of the larger study. Establishment of a rural clinical school in KZN: Using photovoice to elicit views of rural doctors and students P D McNeill,* P N Diab, L Campbell *mcneill@ukzn.ac.za Background. The development of rural clinical schools is becoming a global and a South African phenomenon. Providing a positive experience for staff and students as well as ensuring that the facility still offers a service to the community and fulfils teaching goals are all important concerns. It is hoped that such schools will promote recruitment and retention of rural staff and better sustain rural health services. Method. Purposive sampling of doctors and students working at a rural district hospital in KZN took place. This hospital has been identified as a potential site for a fully equipped rural clinical school within the foreseeable future. Photovoice technique was utilised to elicit views of these participants as to what a rural clinical school would entail with the aim of planning such a school in the future. Participants were asked to take photographs of what ‘life in a rural district hospital’ means to them and their interpretation of these photographs was explored in in-depth individual interviews which were audio-recorded and transcribed for analysis. Ethical permission for the study was granted by UKZN Humanities and Social Sciences Research Ethics Committee (HSS/0076/012). Results. Various photographs taken by participants will be discussed . These speak to the themes of respect for patients, empathy for rural doctors and an understanding of the community they serve. Clinical and logistical challenges of rural hospitals are highlighted as well as the successes possible with restricted resources.

Abstracts Conclusion. This presentation provides valuable insight in a novel manner as to the challenges and successes faced by rural district hospitals. It serves as a vital aid to inform strategic planning for developing a rural clinical school as well as feedback to teaching institutions on curriculum development. Paramedic student perceptions, beliefs and attitudes towards work-place learning B de Waal* *dewaalb@cput.ac.za Background. Workplace learning forms an integral part of emergency medical sciences educational programmes. As part of their learning programmes, paramedic students are required to participate in workplace learning, where they interact with patients in a real-world setting. The goal of workplace learning is to integrate theoretical principles into practice and develop intuitive knowledge for practice. However, the impact of these programmes is not well understood or documented; neither are the beliefs, attitudes and perceptions of the students. Objective. This study aimed to provide insight into how students view workplace learning, identify possible barriers to learning and questions for future research. Method. A cross-sectional descriptive survey was performed, utilising a self-administered questionnaire. A convenience sample of students currently registered at the Cape Peninsula University of Technology for the National Diploma in Emerency Medical Care paramedic programme were asked to participate and complete the questionnaire. Results. A 36% (54/150) questionnaire return rate was achieved. Most participants indicated that they valued workplace learning, and that they enjoyed the experience. In total 98% of participants indicated that they believed experiential learning was directly related to more successful practice, post qualification. When asked about their clinical mentors, most participants indicated that they valued the input of mentors and considered them appropriately equipped to mentor them. Despite this, 38% of participants indicated that it was not uncommon for mentors to treat them harshly. These participants were also more likely to express negative attitudes towards the value of experiential learning. Conclusion. From the findings of this study it can be concluded that participants tend to view their workplace learning favourably; however, negative mentor-mentee relationships may strain or even affect these views, creating barriers to learning. The central recommendation from this research is, therefore, to evaluate mentoring capacity in the field and provide suitable interventions to improve mentoring systems, communication between mentors and educational institutions, and promote capacity building for mentoring in the workplace learning. Clinical associates: The success road of small group discussions F Peters* *frank.peters@up.ac.za Background. Clinical Associates (ClinAs) are trained at three universities in South Africa. They graduate with a Bachelors degree in Clinical Medical Practice (BCMP). The training of these ClinAs is based on distance and service delivery training on site in a hospital. After three years they are placed as ClinAs in a district hospital and always work under the supervision of a registered medical officer.

Objective. How to develop a ClinA in the curriculum, assessment and rotations of these ClinAs working at a Clinical Learning Centre (CLC) with distance learning from the middle of the first year until the end of the third year. Method. When the ClinAs started in January 2011, a comprehensive study guide was handed to them at the 2-week contact session with the uiversity. A CLC with distance learning and service delivery worked out a programme for small-group discussions and clinical rotations in the wards. These smallgroup discussions are based on problem-based discussions. The curriculum of these ClinAs was totally covered with twice-weekly small-group discussions Results. The curriculum is divided in a 3-year clinical study and covers all the medical systems. Assessments are done with observed consultations (Mini CEX) and patient studies, as an assignment, according their clinical rotations. The clinical rotations entitle that the ClinAs work certain hours in the hospital where the CLC is based. We are currently in our 3rd year with this programme and two groups have graduated, completing the degree. Therefore this is a reflective study on what was done in the past years. Conclusion. Small-group discussions with problem-based distance learning and service delivery can cover the curriculum, assessment and clinical rotations to be a competent ClinA. Basic procedures required of 3rd-year medical students during internal medicine junior rotation at CUHAS, Tanzania K Eveline,* J van Wyk *ekonje28@yahoo.com Background. Tanzania has no standardised exit examination to certify the competency required of students at time of graduation. The lack of official documentation, use of different medical curricula, shortage of discipline experts and insufficient clinical exposures result in significant variation in the competencies of medical students. Objective. This study aimed to identify the basic medical procedures that undergraduate medical students should acquire by the end of their junior rotation. It explored the existing level of exposure that students experienced and identified the gap in the 3rd-year curriculum. Method. A cross-sectional descriptive study was designed to capture basic procedures using a self-administered structured questionnaire from 21 experts in the Department of Medicine. Document analysis was done to explore on the gap in the curriculum. The logbooks of 75 students who completed junior rotation in December 2012 were used to determine the level of exposure to the procedures. Results. The response rate was 71%. Participants identified basic procedures that students should perform independently and under supervision. Independent competence was needed for Foley catheter insertion, venipuncture and IV drip insertion, and lumbar puncture while performing thoracentesis and paracentesis, and inserting a nasogastric tube should be done under supervision. The logbooks revealed that the majority of the students assisted with lumbar punctures (54.67%) and performed venipuncture (61.33%). Of concern, a significant number of students (24%) did not practise or perform any procedure. The existing 3rd-year curriculum does not specify clearly the basic procedures that students have to be competent in. Failure to perform basic skills in the junior and senior rotations leads to lack of competence at the end of training. Conclusion. The logbook as an assessment tool is questionable in the absence of a quality assurance mechanism. There is a need for reviewing the curriculum.

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Abstracts Comparing academic performance: Rural versus ‘traditional’ medical training N Kok,* J Bezuidenhout, H Conradie, M de Villiers, T Fish, B van Heerden, S van Schalkwyk *nkok@sun.ac.za Background. As the number of health sciences students participating in prolonged rural-based training programmes increases, the key concerns for these students and faculty are the maintenance of academic standards and whether such training might negatively influence their academic results. At Stellenbosch University’s Ukwanda Rural Clinical School (RCS) medical students spend their final year being trained in either a regional or district hospital. They participate in the same final summative assessment as their peers at the academic training hospital although each of the end-of-rotation assessments includes patient portfolio presentations that are not part of the assessment at the academic training hospital. Objective. The aim of this research was to compare the academic results of two successive cohorts of students trained at the RCS with those trained at the academic hospital. Method. The six-year MB ChB programme covers three phases, including a pre-clinical phase. Results from the middle phase (final mark) and the late phase (end of rotation marks and exam results) were obtained from programme academic files, anonymised and analysed using STATISTICA. Anova and variance estimation tests were performed to explore and compare the results. Results. Although the 2012 cohort entered the RCS with higher average marks than the Tygerberg students for most of the disciplines, their academic performance on the rural platform generally showed an increase relative to the Tygerberg students. Specifically, iobstetrics and gynaecology marks were significantly higher than those of the Tygerberg students (70% v. 65%, p=0.002). There are possibly a number of reasons for this increase in academic performance, which includes the portfolio assessment. Conclusion. Based on the data from the two cohorts it would appear that completing the final year at the RCS did not affect the students` results negatively, but rather suggests that the rural training might have benefited performance in some disciplines. Intervention to facilitate integration of traditional health practices in South African primary healthcare: A 3-year comparative pre- and posttest study M Mammen* *mammen2010@gmail.com Background. It is common knowledge that most Africans grow up with treatments with traditional medicine (TM) and experiences of interactions with traditional healers (TH). Consequently, TM and TH are part of the African culture. Objective. The purpose of the study was to gauge the effect of interventions in order to increase medical students’ awareness, knowledge and attitudes towards practices in TM. Method. This was a longitudinal study conducted at Walter Sisulu University among first-year medical students. Pre-tests were administered in February in 2010, 2011 and 2012. These were followed up with post-tests in June in the respective years after exposure to four interventions: (i) gathering information from their family on medicinal plants that are used to treat

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different illnesses; (ii) collecting one medicinal plant and information about its use from their locality; (iii) presentations and discussions with TH about the role of traditional healthcare in the community; and (iv) visiting a TH’s practice. Data were gathered through structured and standardised questionnaires in order to obtain sociodemographic factors, beliefs and attitudes. A paired chi-squared test was used to measure changes in beliefs, attitudes and practices of students pre-test and post-test. Results. In 2010, of 98 students surveyed, 39%, 59% and 82% were males, females and blacks, respectively; in 2011, of 108 students surveyed, 49%, 51% and 88% were males, females and blacks, respectively; and in 2012, of the 118 students surveyed 42%, 58% and 89% were males, females and blacks, respectively. In 2010, only 45% had beliefs in TM, in 2011 and 2012, 57% had beliefs in TM. However, in 2010 and 2012, 51% and 53% had positive attitudes towards TM, respectively. In 2011, only 42% had a positive attitude. Conclusion. After interventions, and despite the lack of change in belief in TM, there was a significant increase in positive attitude in 2010, 2011 and 2012, i.e. +78% change, p<0.0001; +108% change, p<0.0001; +50% change, p<0.001, respectively. Short educational interventions can positively influence students’ attitude and practices towards TM. Perceptions of graduate-entry medical programme (GEMP) students of assessment in the GEMP I and II curriculum P Mc Inerney, D Manning, P Keene, A Magida* *ayanda.magida@wits.ac.za Background. In 2003 the Faculty of Health Sciences at the University of the Witwatersrand introduced a new medical programme for years III - VI of the MB BCh degree programme, the Graduate Entry Medical Programme (GEMP). GEMP was designed as an integrated, problem-based programme with subject matter arranged in a series of 11 largely organ-system blocks. Objective. The purpose of the study was to evaluate the views of GEMP students on the assessment methods used in the GEMP I and II curriculum. Method. An exploratory descriptive study was conducted among GEMP III students. A self-completion questionnaire was administered to the students. Descriptive statistics were used to analyse the quantitative responses, and content analysis was used to analyse the open-ended responses. Results. A total of N=136 students completed the questionnaires, 67% (n=91) were MB BCh I and II, 26% (n=35) were graduate entrants who entered the GEMP I programme in 2011, and 6 % (n=8) were unknown. Students’ responses showed that they perceived the methods of assessment used in GEMP I and II as valuable and content centred. They have also articulated that the practical component of GEMP I and II provided them with a solid foundation in clinical skills. They have articulated that practical skills are fairly executed and evaluated the established purposes of the various blocks. The students’ opinions concerning the methods of assessment are presented in four themes that emerged from the content analysis. These were: ‘examiner subjectivity’, ‘value of hospital visit days’, ‘standardised methods of assessment’ and ‘topics assessed’. One of the main concerns highlighted by the students is the lack of constructive feedback from lecturers. Conclusion. GEMP III students have generally articulated a combination of positive and negative perceptions about the methods of assessment used in the GEMP I and II curriculum. GEMP III students favour practical forms of assessment more than the assessment of theoretical knowledge.

Abstracts Innovatively adapting a programme to answer the challenges posed by the government and your own institution J J van Rooyen, A Reinbrech-SchĂźtte,* J Hugo *angelika.schutte@up.ac.za Background. In 2011, the Minister of Health promulgated the re-engineering of primary health care (PHC). This innovation involves moving the focus of intervention from institutions (clinics and hospitals) to the community. University of Pretoria (UP) Health Sciences, with collaborators, is setting up health posts in a model. Nine such sites are being established. L-CAS is a medical-education-through-experiential-service-learning initiative that was implemented in the UP School of Medicine. The programme faces logistical challenges, such as limited space and resources at the clinics, that are threatening to impact negatively on it. Objective. The adaptation of L-CAS by supporting the development of learning sites at the COPC health posts in answer to the posed challenge by the minister, and other logistical difficulties such as limited funding and resources. Method. A participatory action research project was initiated to evaluate, review and adopt the L-CAS programme. This project includes questionnaires, focus groups and a workshop. Results. After the initial round of evaluations, a number of proposed changes were identified. These include the development of inter-professional learning, creating a more diverse learning platform, exploring partnerships with students from other faculties working in the same communities, and continuing the research. Some of the main challenges faced are limited funding and resources, as well as negative attitudes of key role players. None of the mentors could be re-employed. Innovative adaptations and restructuring of the Department of Family Medicine were done to address these challenges. Conclusion. Constant re-evaluation and adaptation of a programme are necessary. This could be a very positive experience, provided that change management strategies are in place with the necessary support from key role players. Facilitating work-integrated learning using the case method J du Plessis* *duplesj@cut.ac.za Background. In 2007, a new Higher Education Qualifications Framework was promulgated by the Department of Education in South Africa. Emphasis was for the first time placed on the required work-integrated learning component in the curriculum of envisaged new qualifications by the governing body. In the current wake of re-curriculation of the radiography profession from a National Diploma to a professional Bachelor degree with the promulgated inclusion of work-integrated learning, it became essential to investigate the facilitation of work-integrated learning through different teaching tools. Objective. To investigate third-year radiography studentsâ&#x20AC;&#x2122; conceptualisation and analysis of the content of case studies to facilitate the integration of knowledge as part of work-integrated learning. Method. The 2012 and 2013 third-year radiography students were presented with case studies with different complexity levels and an accompanying set of questions. Quantitative data were accumulated by marking the answers

to the questions and categorising the answers broadly into four groups: (i) only limited information was used to formulate the answers; (ii) only some information was used to formulate the answers; (iii) most of the information was used to formulate the answers; and (iv) all the information was used to formulate the answers. Results. The results indicate that most participants have a limited ability to engage with and critically analyse the content of the case studies. It furthermore indicates a lack of ability in most participants to integrate knowledge from all the different modules/subjects which they were assumed to have accumulated in their first and second year. Conclusion. Facilitators should acknowledge the use of case studies to teach the senior students in the work-integrated learning component of their course to stimulate the ability of critical thinking and problem solving by integrating all acquired knowledge and skills. Interprofessional education in the Faculty of Health Sciences, University of KwaZulu-Natal P Flack* *flackp@ukzn.ac.za Background. This paper describes a model of inter-professional education (IPE) used in the School of Health Sciences at the University of KwaZuluNatal. In this model IPE begins with a foundation module in the 1st year and is then picked up in an academic service learning or clinical module in the 4th year (final year). A theory module, placed early in the curriculum for health science students, was developed from a recognition of the necessity to educate health science students about the link between health, community and poverty, especially in developing countries. Secondly, it was developed from a recognition of the need for dialogue between professionals or multiprofessional interaction. Students complete this 13-week, 72-lecture module by presenting a health promotion workshop to secondary school learners, with the aim of increasing awareness about relevant health issues as well as exposing learners to various health professions as options for tertiary study or career choice. Currently there is little further IPE until the 4th (final) year of study. At this point academic staff and students from three disciplines once again come together in a clinical or service-learning module. The aims of this module include the following: to develop skills for the facilitation of sustainable services in a community context, emphasising training of caregivers, community health workers and other significant individuals; to develop skills for working within a transdisciplinary model of service delivery. Method. This paper presents an analysis of student texts, including reports, journals and exam responses to reveal what they learn from these modules. The focus is on what students learn from each other: about the other professionals, about service delivery, and about the reality and challenge of meeting the patientsâ&#x20AC;&#x2122; primary needs in a context of poverty. This paper is a reflection on the curriculum content, the pedagogy and the outcomes. Results. A number of interesting themes emerge,in four key areas: changing attitudes to other professions; enhancing collaborative behaviour; change in attitude, knowledge and skills; gains in delivery of patient care. Conclusion. It is imperative that in training health professionals for the South African context, there is a process of learning from and about each other, i.e. a shift towards IPE.

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Abstracts Promoting interdisciplinary learning in a multidisciplinary faculty P A Mc Inerney* L P Green-Thompson, S Moch, J D Fadahun O S P Goven *patricia.mcinerney@wits.ac.za Background. The University of the Witwatersrand offers undergraduate degrees in six health science professions. Teaching and learning are usually discipline based with each discipline planning and implementing the curriculum individually. Teachers may teach in other disciplines, but students generally do not learn together. Method. The medical students begin clinical practica in their third year of study. At the beginning of the third year, students are allocated to wards to work with nurses. During this placement, students are required to participate in all the nursing activities, such as bathing and feeding of patients, bed making, and administration of medications. The value of this experience has been documented in students’ portfolios of learning. The second interdisciplinary experience that the medical students have been exposed to is having pharmacy students accompany them in the wards during their practica. There are usually 3 - 4 medical students and 1 - 2 pharmacy students who, as a group, are allocated to a particular ward. They are required to take patient histories and examine patients. Results. Students have described the value of both types of learning experiences, in particular noting the value of learning about the roles of other disciplines, the development of respect for what the other does, and the value for the patient when there is interdisciplinary care. The value of both these learning opportunities can be aligned with Kolb’s experiential learning cycle. Conclusion. Interdisciplinary learning opportunities are valuable for both the student and the teacher as relations between the disciplines are fostered. Interdisciplinary learning opportunities need to be identified and encouraged to promote multidisciplinary care. Introducing sexual and gender minorities teaching V Mitchell,*A Kent, A Muller, C Gordon *nicamitch@mweb.co.za Background. A curriculum mapping exercise at the University of Cape Town (UCT) in 2012 revealed limited tuition in the field of lesbian, gay, bisexual and transgender (LGBT) persons’ health needs. Following discussion by the Faculty MB ChB Education Committee, the Department of Obstetrics and Gynaecology indicated a special interest to include the teaching of gender and sexual orientation issues in its curriculum. Objective. To introduce sexual and gender minorities (SGM) teaching into the medical undergraduate clinical curriculum in a scholarly manner. Method. The Department of Obstetrics and Gynaecology made space available in the Year 5 clinical timetable for student-led workshops. The workshop design is presented to students at their introductory gynaecology session. Small groups of approximately 10 students select topics from a range of LGBT issues. They prepare and present to the larger group 6 weeks later. Dialogue is facilitated by departmental educators and an expert in LGBT health. Surveys conducted at the start of the group sessions are followed by interactive participatory presentations, which include videos of interviews, video-clips, PowerPoint presentations, debates and personal insights. Workshop evaluations provide student feedback. Students also

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submit reflective commentaries at the end of the block as a compulsory task, with anonymity assured. Qualitative analysis of the surveys and workshop evaluation responses will be presented. Results. The classroom survey and students’ comments have reinforced widespread concern that this important aspect of patient care has previously been missing from undergraduate curricula. The workshops were enthusiastically prepared for and presented, with encouraging evaluation comments received. Conclusion. Healthcare for sexual and gender minorities is a neglected aspect of instruction in the MB ChB clinical curriculum and its successful introduction at UCT has been well received. All health science faculties should consider teaching curricular content specific to the needs of sexual and gender minorities. Introduction of a personal and professional development module in the undergraduate medical curriculum B S Subramaniam, S Hande,* K Ramnarayan *hande2010@gmail.com Background. The MBBS curriculum of the Melaka Manipal Medical College (MMMC) is a five-year academic programme with the first two and half years in India and the next part of the programme in Malaysia. MMMC has adopted a six-strand curriculum introduced in September 2006. The personal and professional development (PPD) module runs vertically throughout the first part of the programme. Objective. To introduce and sustain a PPD module in the undergraduate medical curriculum Method. Firstly, one hour per week of PPD was incorporated in the timetable for the first-year MBBS students. Students were introduced to topics such as medical humanities, leadership skills, communication skills, ethics, professional behaviour and patient narratives. In the second year, students are required to pursue a group project of their choice, under a faculty mentor. A faculty co-ordinator was selected to identify and deliver relevant topics. All faculty were requested to select topics of their choice which they could conduct in an engaging manner. An assessment was made by two batches of students. Results. The majority (80%) of students agreed that the module was well prepared. Students assessed the modules as useful because they saw improvement in their affective skills. They rated the topics as ‘highly relevant’ to the medical course. Faculty found the topics new and interdisciplinary. The handling such topics, and creating interest and engaging the students were a challenge. There was however a sense of sharing responsibility and workload by the faculty. Conclusion. The positive response of the students towards the PPD module was encouraging. However, in order to sustain the module it needs to be reviewed and renewed frequently. Social accountability: Hearing community voices L Green-Thompson* *lionel.green-thompson@wits.ac.za Background. Social accountability of educational institutions has been defined as responding to defined communities’ needs in the area of research, service and education. The Lancet Commission has recommended the

Abstracts transformation of educational programmes in the health professions to produce graduates who are change agents responsive and accountable to the communities that educate them and in which they are called to serve. There is little information from rural communities in South Africa about their expectations of medical practitioners. Medical students at Wits University have contact with rural communities in three provinces. Method. Focus groups were held in several communities in which Wits medical students have clinical clerkships. These groups were selected together with the co-ordinators of the community sites, and included young people, traditional healers and older members of the community. The numbers in each group varied from 6 to 12 participants. Participants were not in need of medical attention at the time of the interviews. Some of the focus group discussions were conducted in the vernacular of that region with the aid of an interpreter. Results. Members of communities responded positively to the invitation to participate in the focus groups. Three main themes have emerged from the focus group discussions: • Doctor-patient relationships. Participants generally reported negative experiences of their encounters with doctors in the public sector, with many perceiving the treatment received from the same doctor to be better in private practice. • Respect and love. For many participants, social accountability of doctors is the expectation that doctors treat them with ‘respect and love’. • Identification of health priorities. Participants describe both social determinants and medical conditions as being a part of their communities’ health priorities. Conclusion. While communities may not be familiar with the phrase social accountability, they are able to define their health priorities. In the context of these priorities there is an expectation that doctors’ behaviour is governed by their respect for patients. There is a need for increasing the active involvement of communities in developing the definitions of social accountability. Communities may offer unique insights to how we develop social accountability thinking. Peer review for social accountability of Health Sciences Education: A model from South Africa D Michaels,* S Reid, C Naidu *des.michaels@uct.ac.za Background. The Collaboration for Health Equity in Education and Research (CHEER) is unique in the composition of its members who represent all the faculties of health sciences in South Africa. Over the past 10 years CHEER has conducted 18 peer reviews involving all the institutions. In August 2012 CHEER embarked on its pilot peer review on Social Accountability in Health Sciences in South Africa. Objective. This paper shares lessons and insights from the pilot process. Method. A descriptive study design, using qualitative methods which focused primarily on semi-structured interviews and focus group discussions, supplemented with supporting documentation, was employed. Results. Several key components of the review process that should be noted for future reviews on scial accountability were identified, i.e. (i) the composition of the review team; (ii) the review process; (iii) data collection

and analysis; and (iv) the reporting process. Peer review is a useful way of building consensus and a common set of values that become more explicit through the process. We found that six criteria, namely, values, reference population, partnerships, student profile, graduate outcomes and impact, provide the basis for establishing standards for reflecting social accountability in health sciences faculties. Peer review is a process of institutional self-review supported by ‘a panel of critical friends’ and is useful when considered as part of the process of preparation for the formal accreditation review at health sciences educational institutions. Conclusion. The CHEER collaboration has entrenched the culture of peer review among all the faculties of health sciences in the country and thus laid the foundation for designing standards to reflect social accountability specific to South Africa. However, it is universally applicable due to the diverse nature of the context of the various faculties of health sciences in South Africa. The process followed and experience gained in South Africa may therefore be useful in other countries. Successful interventions to improve human resources for health: The Stellenbosch University Rural Medical Education Partnership Initiative M de Villiers,* J Nachega, K Moodley, L Dudley, S van Schalkwyk *mads@sun.ac.za Background. Stellenbosch University was among 13 African Universities awarded the Medical Education Partnership Initiative grant aimed at improving human resources for health in Africa. SURMEPI specifically aims to improve the quality and quantity of healthcare workers, retention in areas of need, and regionally relevant research. Method. The project focuses on the development and evaluation of innovative medical education models that aim to support rural and underserved communities. The project uses two foci, i.e. medical curriculum renewal and health systems strengthening and development, to render the delivery of transformative systems-based education. Results. Year three of the grant has shown significant outputs in training approximately 550 healthcare workers and faculty in public health, PALSA PLUS, evidence based healthcare, infection prevention and control, and HIV/TB management. In addition, SURMEPI has provided 21 undergraduate students with funding for rural electives in the African region. Eight PhD and 18 Masters students conducting research in rural areas have also been supported through mentorship and funding. A wide variety of research capacity building courses has been offered to undergraduate and postgraduate students, including faculty. Interdepartmental collaborations have led to a more context-specific, systems-based approach to medical education integrally linked to the graduate attributes of SU. Electronic learning has been a cross-cutting theme in SURMEPI, resulting in a shift and recognition of the benefits of eLearning for medical students at central and rural sites. SURMEPI has embarked on several African collaborations to develop family medicine and research capacity building in the region. Conclusion. In the short time span of approximately three years, SURMEPI has achieved significant outputs that will ultimately contribute to the goal of transforming medical education and improving human resources for health in rural Africa.

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Abstracts The relationship of health science faculties to their health service partners: Implications for clinical teaching in South Africa S Reid,* D Michaels, C Naidu *cha.johnston@uct.c.za Background. Health science faculties in South Africa largely rely on public health services for student access to patients for clinical learning in hospitals, clinics and other facilities on the service platform. The relationship between faculties and their respective provincial health service partners has been a source of concern, but has not been studied in South Africa. Objective. To describe the relationship between health science faculties in South Africa and their respective service partners with respect to clinical teaching. Method. A series of peer reviews following a standard protocol were carried out at nine health science faculties in South Africa, including eight schools of medicine, from October 2009 to February 2013. Review teams of four spent 3 days at each faculty interviewing university staff, health service staff, and students, and examining relevant documents. A comprehensive report on each review was produced and presented to the faculty concerned. An overview of the peer reviews is presented here. Results. The nature of the relationships varied widely, ranging from transactional arrangements based on formal legal agreements at institutional level to informal arrangements at local level. Generally relationships were found to be positive and mutually beneficial at local facilities, where students are well integrated into the delivery of services. Sources of tension include too many students in facilities, lack of resources for clinical learning, and inadequate supervision. The variety of relationships are described and classified. Conclusion. Effective clinical teaching is highly dependent on a stable and conducive environment for access to patients by students and staff. This needs to be supported by institutional relationships that understand the challenges faced by each partner, as well as adequate resources for clinical learning. Cross-cultural medical education: Using narratives to reflect on experience P N Diab, T Naidu,* B Gaede, N Prose *naidut10@ukzn.ac.za Background. Educating students within a multicultural society has become a challenge as teachers, students and the community they serve all tend to represent various social groups. Skills alone are not adequate for competency in understanding cross-cultural consultations. A combination of knowledge, skills and attitude is the most widely accepted current approach to teaching culturally competent communication to medical students. The utilisation of collaborative reflection is a useful tool in developing these attributes. Method. An interest group of medical teachers met to address the specific needs of teaching a relevant cross-cultural curriculum. Participants in the group offered narratives from their professional life and collaboratively reflected on these encounters in order to understand how to improve the current curriculum to better address the needs of the students and patients they serve. Results. Through narratives, participants were able to reflect on how their experience had allowed them to develop cultural awareness. All stories

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represented how attitudes of respect, curiosity and unconditional positive regard were held above all else. It was through collaborative reflection with peers that these stories were further enhanced and different learning opportunities discovered. These real stories with real patients also were able to personalise the learning opportunity for the listener. Conclusion. The use of collaborative reflection on the narratives of clinical encounters could facilitate insights about cultural aspects of medical practice. Elements such as curiosity, respect and unconditional positive regard are illustrated in a unique way that allows students to appreciate the real-life aspects of cross-cultural clinical encounters. Social accountability: Using a first-year project to advance the mission of a medical school J van Wyk,* S Knight *vanwykj2@ukzn.ac.za Background. Medical students generally struggle to understand the public health perspective of their studies in clinical medicine and can become disillusioned, disengaged and disappointed in their undergraduate public health curriculum if the relevance of the discipline does not become clear to them. A novel community service activity was introduced for firstyear medical students from the University of KwaZulu-Natal in 2012, which expects them to work in self-selected groups of 3 - 4 students in disadvantaged communities of their choice. They are required to spend at least 16 hours engaged in a community service in the community that are in close proximity to their term-time residence. In an effort to evaluate the first-year curriculum’s responsiveness to community needs, we draw on an amended framework by Woollard and Boelen (2012) to discuss the success and challenges of the Making a Difference project. Method. Data for this observational descriptive sectional study was collected in 2012 from the first-year student groups. We report on students’ reasons for having selected a specific community, their aspirations on how they had hoped to make a difference in the community, and how they learnt became transformed due to their engagement on the project. Results. Preliminary findings suggest that the project allowed students, who tend to alienate themselves when entering tertiary education, to engage with disadvantaged communities near their term-time residence in Durban. They contextualised the theoretical knowledge learned on health systems in their module. Students became aware and applied ethical principles in their interactions with diverse and vulnerable groups. Some reported that it was a ‘humbling and a huge learning experience’ and finding ‘happiness in life’s simplest gifts such as friendship and acts of kindness’. Conclusion. It is possible to devise a curricular intervention that develops generic attributes and research skills in students, assists them to understand the relevance of public health, and embraces principles of social accountability. Community engagement on ward-based outreach teams: New context, new learning J Hugo,* T Marcus *jannie.hugo@up.ac.za Background. The Longitudinal Community Attachment for Students (L-CAS) at the University of Pretoria for medical students has been running

Abstracts since 2008. Since 2010 the Department of Family Medicine, in collaboration with the Tshwane District, developed ward-based outreach teams as part of the Minister of Health’s re-engineering of the primary healthcare initiative and part of the NHI pilot project in Tshwane District. The initial successful ward-based outreach teams created a new context for community engagement. Objective. To shift the engagement of students from a facility-based engagement to family- and home-based engagement within a communityoriented primary care (COPC) framework in communities Method. Since 2012 students were allocated to clusters, each linked to a ward-based outreach team. The fourth-year medical students did most of their 16 days L-CAS rotation at these sites, accompanying community health workers to homes, assisting with patient assessment and sharing knowledge with community health workers. In 2013 MMed registrars in Family Medicine were allocated to each of the ward-based outreach teams as part of Family Medicine postgraduate training. Their role is to support and develop the ward-based outreach teams, do research and mentor medical students. Results and Conclusion. Students’ experience is significantly different in the ward-based outreach teams compared with district clinics. The extent of poverty, the prevalence of epidemic conditions and social conditions, e.g. drug dependence, is much clearer in the communities. The structure and functioning of the ward-based outreach teams provide a structure for intervention and hope for successful intervention. Early experiences of postgraduate and undergraduate students will be presented. Ward-based outreach teams and re-engineering of primary health care provide a crucial context for community engagement and are excellent for learning while student engagement enhances their functioning. Towards the development of a definition of service learning: Converging conflicting mind maps H Julie* *hjulie@uwc.ac.za Background. Research on the conceptualisation of community engagement and service learning indicates that concepts such as service learning, community engagement, community service and scholarship of engagement are used interchangeably. Academics at the research institution were experiencing difficulties in implementing service learning because of their diverse and conflicting conceptualisations of it. Objective. To develop a relevant construct of service learning for the School of Nursing. Method. This study used the Nominal Group Technique as a means of gaining consensus from a diverse group of academic staff about the main concepts that should be included in the definition of service learning for a school of nursing. The following steps were used: 1. individual generation of ideas 2. recording of all participants’ ideas (in a round-robin format) 3. group discussion of all generated ideas (to organise the list and remove duplications) 4. preliminary vote to select the most important ideas 5. group discussion of the vote outcomes (including additions and further merging of overlaps) 6. final voting on the priority of items.

Results. The following concepts were ranked as the six most important by 13 key informants: equal tri-partnership; reflective practitioners, teaching and learning; community needs; community development; shared values and community engagement. Conclusion. The strong consultation and democratic methods used within the nominal group process allowed the academics to take ownership of the development of a definition of service learning for the school. Better consultation skills through quality improvement J Hugo,* P Kenny *jannie.hugo@up.ac.za Background. Block 16: Health and Health Care. This is a 4 week rotation with 11 days in clinics. Students do a quality improvement project as part of service learning, and patient care in district clinics. One of the key purposes of the block is to do patient-centred consultations. Objective. To learn about quality improvement and peer review through improving their own consultation skills. Method. Students work in groups, which form the QI team with patients. They use a Consultation Peer Assessment Tool developed by the department, based on the Leicester Assessment package adapted to fit in the Juggling Model of consultation. This tool consists of a detailed checklist of main areas of facilitation, problem solving and collaboration and 3 open-ended questions: ‘What went especially well?’; What does he/she still need to improve on?’; and ‘How can I help him/her to achieve these improvements? They also get feedback from patients through the Patient Enablement Instrument. Within the QI cycle, students use the tool as standard to assess present practice through observed consultations. Then they reflect on the current practice, make plans and change practice. In the last week they re-assess the consultations and then write a QI report. Results. Students report on significant improvement in consultation skills with specific reference to important elements of a patient-centred consultation, e.g. use of silence, hand washing, 3-stage assessment and plan, and collaboration with patients. Patient feedback varied but had significant impact where it was specific. Results of a qualitative assessment of QI reports will be presented. Conclusion. QI of own consultations using a structured, detailed tool and involving peers and patients helps students to receive constructive feedback and improve their consultation skills. Self-perceived confidence levels of community health workers to carry out their roles within the primary healthcare outreach teams A Dreyer,* J Frantz, I Couper *abigail.dreyer@wits.ac.za Background. Community health workers (CHWs) will be employed by Government and will be part of the ward-based primary healthcare outreach team. Their role is seen in strengthening health promotion and prevention. The training of CHWs to fulfil their roles has been tasked to non-governmental organisations. The curricula contain the theoretical base but the practical application of the skills/abilities needed to fulfil their roles has not been included. Objective. This study investigated the confidence levels of CHWs related to their roles and responsibilities within the ward-based outreach teams in a sub-district in the North West Province.

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Abstracts Method. Levels of confidence were measured by means of a Likert scale, which was distributed by means of an online survey. This was used to identify the areas for capacity building needed and to develop the training intervention. After completion of training the same survey was completed again and pre-/post- comparisons were made. Data were captured using Survey Monkey, with analysis of frequencies and cross-tabulations on quantitative variables. Results. The gender of participants was 98% female. Participants had been working in their communities, doing home-based care, for more than two years prior to them being recruited for the outreach teams. There was a significant increase in the confidence levels regarding skills and ability post intervention. Sixty-eight per cent of participants’ confidence levels in terms of working in ward-based teams increased post intervention. The participants not feeling confident to collect information shifted from 88% to 12% post intervention. Conclusion. The mastery of skills needed to fulfil the tasks has a direct impact on the confidence of CHWs. Their input in identifying the skills gap added to the value placed on the training. The impact of a service learning module on junior health sciences students A de Villiers,* A J N Louw, M H P van Heusden *adeledev@sun.ac.za Background. In the past, first-year medical and physiotherapy students participating in the Extended Degree Programme (EDP) spent eight weeks shadowing interns in a tertiary hospital during a clinical module. In 2011 student numbers had doubled from the previous year, making it impossible to accommodate the entire group in the clinical setting. Consequently, the group was divided in two, allowing the one group to participate in a servicelearning project while the other spent four weeks in the clinical setting as before. The two groups switched after four weeks. Method. A qualitative approach was used to determine students’ perceptions of the service-learning project. Data were obtained from structured reflective reports about student experiences of the one-week period during which they taught first aid to high-school learners. Open-ended, writtenresponse questionnaires were completed by students. At the end of the four weeks the project generated further useful data regarding the logistics and administration of the project as a whole. Results. Similar to findings reported in international studies, analysis of qualitative data indicated an increase in student motivation in terms of their studies and vocation; an enhanced sense of civic responsibility and social justice; improved group interaction and personal communicational skills; as well as an increase in compassion and a decrease in racism. Conclusion. Besides gaining first aid knowledge and skills, students spent time with a community they might not necessarily have encountered under normal circumstances. They became increasingly aware of the population they would be serving once they graduated as well as their role as professionals within this community. A service-learning teaching strategy may contribute in producing service-driven and culturally competent physicians as well as those who will serve as community leaders, for reasons such as the following: ‘... there are lessons one needs to experience rather than to be taught’. [EDP I student].

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Rethinking the wheel: A clinical presentation-oriented internal medicine curriculum for South Africa J A Coetser* *coetserja@ufs.ac.za Background. An increased emphasis on primary healthcare in South Africa, a political mandate to align medical education with socio-epidemiological need, and the introduction of community-based education (CBE) at the University of the Free State (UFS) havenecessitated review of the undergraduate curriculum in internal medicine. A clinical presentationoriented model is being developed. Objective. To compile a consensus list of common clinical presentations and their respective differential diagnoses for medical patients in South Africa. Method. From March 2012 to January 2013, 11 expert work groups, each consisting of at least the unit head and one consultant of the UFS Department of Internal Medicine subspecialties, were asked to compile a consensus list of the most common primary clinical presentations for patients presenting to their subspecialty, as well as the most common and important differential diagnoses for these presentations. The general medicine work group reviewed these lists for completeness and applicability to the South African primary healthcare setting. Results. A total of 111 common clinical presentations were identified. The most frequently listed were tiredness/fatigue (50%), shortness of breath (50%), fever (50%), weight loss (50%) and chest pain (40%). For all presentations a total of 670 differential diagnoses were generated (clinical presentations/differential diagnoses): cardiology (10/48), endocrinology (28/137), gastroenterology (14/78), geriatrics (8/30), haematology (14/38), infectious diseases (19/109), nephrology (11/34), neurology (13/63), pulmonology (16/71) and rheumatology (12/62). Conclusion. This study represents the first step towards developing an undergraduate clinical presentation-oriented curriculum that is tailor-made for South Africa’s health milieu. Does the BPharm curriculum of TUT/UL (Medunsa campus) prepare graduates to be competent community pharmacists? G M Enslin,* J Snyman, E M Reeber, A A Abisola, S I Mahlangu, M C Masingi, N F Mogane, S B Sombili *enslingm@tut.ac.za Background. The joint TUT/UL (Medunsa) BPharm programme has been offered since 1999, using problem-based teaching and learning methodology with the aim of producing graduates with the required skills, knowledge and attitudes to serve the pharmaceutical care needs of the South African society. The contribution of the learning programme to the achievement of the required competency outcomes related to community pharmacy practice was investigated in this survey. Objective. To identify the role of the BPharm learning programme in ensuring competency of pharmacists and interns in the community pharmacy sector. A survey was conducted to identify gaps in the curriculum and/or learning programme. Possible measures to address these gaps are suggested. Method. The curriculum and learning programme of the TUT/UL (Medunsa) programme were assessed against the 2004 competence standards of the South African Pharmacy Council.

Abstracts A cross-sectional survey of TUT/UL (Medunsa) BPharm graduates was conducted. A convenience sample of 19 pharmacists or interns working in the Pretoria area were interviewed using a semi-structured questionnaire. Ethical approval for the study was obtained from TUT. Results. The BPharm modules curriculum was found to address the requirements for competence in the community pharmacy sector. In the section of the questionnaire dealing with knowledge skills and attitudes, most participants identified the community pharmacy module as the module that prepared them best for community pharmacy practice. Ten other modules were identified as helpful. As community pharmacy is one of four sectors for which students are prepared, this result was expected. Interestingly, only five participants identified the work-integrated learning module in community pharmacy as helpful. The most important skills acquired at university, according to participants, were communication (74%), management skills (32%) and interpersonal skills (26%). Of the competency standards selected as most relevant to community pharmacy, monitoring drug therapy and implementing a pharmaceutical care plan were reported as being moderately difficult or difficult to practise. Conclusion.The study found that the curriculum adequately addressed all areas of knowledge, skills and attitudes to allow graduates, in their opinion, to practise competently as community pharmacists as specified in the competence standards of the South African Pharmacy Council. Some recommendations were made with respect to preparing graduates to be mentors and to introduce mechanisms to focus on how to keep up to date with new laws and regulations, pharmacy management skills, pharmacovigilance and new drugs. Oral hygiene lecturers’ perceptions of knowledge and curriculum issues at three training institutions in South Africa G Vergotine,* Y Shalem *glynnis.vergotine@wits.ac.za Background. There has been growing discussion in the oral hygiene literature regarding knowledge and professionalisation that influences the field of practice. Examining lecturers’ perceptions of knowledge, curriculum issues and ways of socialising students into the field will be help to investigate this. The results provided here are from a project in progress. Objective. To examine South African oral hygiene lecturers’ perceptions of knowledge and their curricula. The purpose was to collate demographic information of the lecturers and to gain information on their perceptions of their curricula. Method. Fourteen questionnaires were delivered to full-time lecturers in oral hygiene (degree course). Ethical approval was granted by the Wits Education Ethics Committee. Results. Seventy-one per cent (n=10) lecturers responded and demographics showed the following: 70% were ≥45year; 50% completed an educational qualification; 4 completed a Masters degree and one a PhD degree; and 90% had >14 years of teaching experience. With regard to what prepared them best for teaching oral hygiene students, 50% indicated that they drew from their qualification in oral hygiene, other degrees and education courses, while two indicated that they used their practice experience. All teach clinical subjects, with three teaching specialised areas. Research activities varied according to qualifications and areas of interest. Main resources selected for informing their teaching was textbooks and journals, while the internet and seminars were less frequently used. Seventy per cent felt that

oral hygiene specialises in prevention and health promotion. They indicated that oral hygiene knowledge is drawn from mostly dentistry, and less from anatomy, pathology and microbiology. Disciplines such as psychology, sociology, education and nursing were not seen as contributing much to the knowledge base. All respondents were involved with curriculum development, planning and implementation. Conclusion. The results showed that oral hygiene lecturers had the capabilities to be reflective about the knowledge needed for their curricula. A needs assessment of medical student education in the Department of Paediatrics and Child Health at the UZCHS: Towards a new curriculum H A Mujuru,* J Frantz *hmujuru@mweb.co.za Background. The existing medical education curriculum in the University of Zimbabwe College of Health Sciences (UZCHS) was developed in 1985, reviewed and updated in 1992, and revised in 2006 to include HIV/AIDS. The degree to which this revised curriculum is being implemented and its adequacy in addressing current health problems is unclear. Objective. To explore faculty perceptions of gaps in the paediatric aspect of the current medical curriculum. Method. A qualitative study was conducted using an intervieweradministered questionnaire. All responses were recorded and transcribed manually. Three independent assessors conducted the thematic analysis. Results. Of the 14 faculty, 10 (71%) were interviewed. There was an average of six years experience (2 - 34) and two lecturers (20%) had ever accessed the UZCHS curriculum. Themes that emerged included lack of alignment between content and student assessment to curriculum purpose, barriers to effective teaching, poorly structured clinical teaching, lack of understanding of different clinical teaching methods and inadequate time for year 5 students. There was consensus on appropriate assessment methods for both the written and clinical examinations but with no system of ensuring that the assessment was based on taught content. Most faculty are junior and inexperienced and would benefit from guidance from an updated curriculum. Though students have a logbook, most faculty teach on whatever cases are in the wards; this needs restructuring. An updated curriculum would guide student assessment in line with content taught. Clinical teaching methods should be stated in the curriculum and faculty development workshops conducted to capacitate faculty. OSCE was the best clinical assessment method, with MCQ and essays the best methods to assess students’ knowledge. Conclusion. An updated curriculum is fundamental for guiding faculty on teaching and assessment of undergraduate students in paediatrics at UZCHS. HIV- and AIDS-related essential competencies for nurses in South Africa: Nurse educators and nurses in clinical practice identification R R M Modeste,* O Adejumo *rmodeste@uwc.ac.za Background. South Africa has an enormous task of providing care and management to those who are affected by and infected with HIV. Similarly to what is done around the globe, South Africa has adopted the global move that when providing health services to patients living with HIV and AIDS, there should be provision of integrated services addressing various

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Abstracts patient needs through a continuum of care. As nurses form the bulk of healthcare professionals in South Africa, they are primarily responsible for the care and management of patients living with HIV and AIDS. It has been reported that during pre-service training, nurses in developing countries are not adequately prepared for HIV and AIDS care and management. This highlights the need to adequately train nurses so that they are able to provide care in line with national priorities and strategies. Objective. To identify nurse educators and nurses in clinical practice with regard to essential HIV and AIDS-related competencies for nursing care and management in South Africa. Method. The study was conducted as a qualitative approach with an exploratory design. The nominal group technique was used to conduct group discussions with nurse educators (lecturers) in six provinces. In addition, individual interviews were conducted with six nurses in clinical practice. Results. From the analysis, 10 competency categories such as counselling, ethics and policies related to HIV and AIDS have been identified, with specific aspects of knowledge, skills and attitude providing further insight into what is expected for each category. Conclusion. The findings of this study allow systematic integration of these competencies into the nursing undergraduate curriculum in South Africa so that educators and practitioners are on the same page. Engaging students through interactive e-guides and multimedia in a flipped classroom approach C Botha,* G Reitsma *chrisna.botha@nwu.ac.za Background. Technology has resulted in changing the classroom as the central point of learning to just one of the interfaces where learning takes place. The use of technology and specifically multimedia has extended the teaching-learning experience to outside the classroom. This motivated the lecturer of a second-year nutrition module to re-think her approach to teaching and learning by moving into a blended learning approach. Objective. To report on the experiences of both the students and the lecturer in changing from a mainly traditional face-to-face class to a flipped classroom supported by technology in the form of an electronic interactive study guide. Method. A mixed-method approach within an action research paradigm was followed. Quantitative methods included a student survey on perceptions and expectation on the use of e-guides at the beginning of the semester, followed by a survey on their experiences at the end of the semester. Qualitative methods included lecturer and student reflection as well as focus group discussions with students. Results and Conclusion. Preliminary results indicate that the students were initially skeptical about the use of technology outside the classroom, but once they were used to the e-guide, they engaged more with the course content both inside and ouside of the classroom. Problems experienced by the students were mainly of a technical nature. The lecturer indicated that she underestimated the planning, time and effort needed to change a traditional hard-copy study guide into an interactive e-guide. However, it would seem as if the incorporation of technology in a flipped classroom added significant value to the teaching-learning experience. The reasons why students experienced this blended learning environment as positive or

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negative still need to be investigated through focus group interviews at the end of the semester. ‘You expect me to do what?’ Student experiences of strategies for enhancing engagement L Keiller,* G Inglis-Jassiem *lkeiller@sun.ac.za Background. The relationship and inter-relationship between the selfdirected learning and group phases of problem-based learning (PBL) are important for learning. Third-year physiotherapy students have very little time to process and fully engage with PBL case content in their PBL curriculum at Stellenbosch University (SU). This could have implications for the way in which students understand and are expected to apply the knowledge in clinical settings. Objective. To determine students’ experiences of the use of technology (videos and blogging) to enhance engagement with content in their PBL module. Method. A mixed methodological approach was used. Participants (N=40) completed a needs analysis survey regarding levels of engagement and preand post-test self-assessment questionnaires. A video camera was available for recording practical techniques during cases and the blog forum for inter-class discussions. Two focus group discussions were conducted and transcribed by independent research assistants. Results. Focus group discussions highlighted the students’ lack of selfdirected learning tendencies and their dependence on lecturers for enhancing engagement. The themes that emerged from the discussions were lecturer responsibility, student responsibility, engagement, technology issues and time. Surveys showed that the students perceived themselves as actively engaged in PBL discussions during cases, but found that there was not enough time given for each case within the module. However, there was minimal use of the technology introduced by this study. Conclusion. Students recognise the value of videos for clinical practice, but do not want to take the responsibility for initiating this learning opportunity. A recommendation of this study is for a video database of clinical skills to be developed in a partnership between lecturers and students. The perspective of radiography students regarding practical demonstrations recorded on video B van der Merwe* *bevdmerwe@cut.ac.za Background. Radiography students at CUT spend up to 40 hours either in the classroom or in the clinical setting. Students spend time in the clinical setting with qualified radiographers and radiologists, performing various radiological procedures. It is not possible to demonstrate every procedure individually to each student and some procedures are never observed by students. Quality mentoring in the workplace is not guaranteed. Large classes, and the unavoidable absence of students or lecturers, added to the challenge of exposing the students to the vast number of procedures covered in the curriculum. Video recording of the demonstrations of the different procedures seemed the obvious solution to build a library of demonstrations of basic concepts consistent with those demonstrated in the classroom. Objective. To determine if students benefit from video demonstrations and if the classroom demonstration is redundant.

Abstracts Method. Lecturers and the audiovisual department recorded video demonstrations of basic routine procedures with standardised patients. Questionnaires were distributed to different student year groups after being exposed to the videos and the current demonstrations to determine the perception in terms of usefulness to their learning. Results. This presentation comments on the advantages and disadvantages of the live demonstration compared with the video demonstration. Videos appeal to different persons as it becomes very difficult for the students to interact with each other. One student summed it up: ‘I think it is beneficial for after class demonstrations as you see clearly in the video it sinks in, it falls into place’. Conclusion. Video tutorials need to be accompanied by well-defined instructional purposes and outcomes to be a powerful educational tool to engage the student in the learning process. ‘Liking’ public health: Exploring social media for teaching public health L Wolvaardt,* L Majake, P du Toit *liz.wolvaardt@up.ac.za Background. Educators in public health report the limited curricular time, disinterest on the behalf of medical students and the scarcity of public health educators as major barriers to the inclusion of public health in the medical curriculum. Social media holds the potential to overcome the time restrictions in busy clinical curricula as well as the opportunity to engage outside the lecture halls. Such a strategy is, however, dependent on student participation in social media. Objective. To determine the use of social media among medical students at the University of Pretoria. To explore any associations between medical students’ use of social media and their knowledge of public health. Method. A descriptive cross-sectional study. Questionnaires with 1 openended question and 45 close-ended questions were distributed by research teams of medical students and academic staff in 2012. Students completed the survey on site, as a 10-item test-your-knowledge quiz was included. Results. A total of 589 medical students participated; 93% of respondents reported using Facebook, with almost half (48.2%) accessing it several times a day. Another 31.6% reported daily Facebook use. Google+ was the second most popular (67.1%) amongst respondents. No association was found between gender and the use of Facebook, Twitter or LinkedIn. There was a significant association (p=0.002) between male students and never using Google+. Students in third year and higher were more likely to use Facebook several times a day (Pearson χ2=54.29 (p<0.000)). A significant association was found between the public health knowledge score and those using Facebook (daily and several times a day) scoring higher in the test (p<0.000). Conclusion. Social media – Facebook in particular – is widely used and is therefore a feasible strategy for public health educators. The higher knowledge scores by regular users also suggest Facebook could be a powerful educational strategy.

Adherence to adult learning principles and professional development among medical school faculty R R Abraham,* A M Ciraj, V Pallath, K Ramnarayan, A Kamath *reemabraham@gmail.com Background. Professional development should not only aim by formal and informal means to help medical educators learn new skills, but also focus on developing insights into pedagogy and their own practice. Understanding adult learning principles is essential to instil professional development. Melaka Manipal Medical College (MMMC), Manipal University, India, offers a five-year Bachelor of Medicine and Bachelor of Surgery (MBBS) programme. The faculty at MMMC are involved in teaching medical, dental and allied health science students. Objective. To attemp to determine whether faculty members at MMMC perceive adult learning principles as a pathway for professional development. We were also interested to know whether any correlation existed between faculty perceptions of adult learning principles and professional development at three levels, i.e. individual, interpersonal and organisational levels. Method. A questionnaire comprising items focusing on five adult learning principles (active participation, relevant learning, safe and non-threatening environment, constructive feedback, previous experiences) was designed. A second questionnaire focusing on professional development at three levels (individual level, interpersonal level, organisational level) was also designed. Faculty members (N=42) were asked to reflect on the practices outlined in both these questionnaires on a 5-point scale. Results. Comparison of mean values of five adult learning principles revealed a high mean value for relevant learning followed by constructive feedback, previous experiences, safe environment and active participation. Correlation analysis revealed a strong correlation between active participation and three levels of professional development and also between constructive feedback and three levels of professional development. Conclusion. In the present study, overall, a strong correlation was observed between adult learning principles and the three levels of professional development. This study intends to provide a framework for professional development centred on a few practices based on adult learning principles. Faculty recruitment and retention in the medical education partnership initiative (MEPI) schools E Kiguli-Malwadde,* F Omaswa *kigulimalwadde@gmail.com Background. The US Government awarded grants to 13 African institutions. The aim is to increase numbers and quality of health care workers, retain them where they are most needed and improve locally relevant research capacity. Mullan et al. noted that there is a great shortage of faculty in subSaharan African medical schools. This negatively impacts on the training of health professions in the region.

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Abstracts Objective. To establish the number of faculty at the MEPI schools, faculty: student ratios, and what the schools are doing to ensure they retain their faculty. Method. Yearly surveys were sent out to the schools and data analysed. Results. There was an average of 204 full-time medical school faculty among the 13 institutions. These ranged from 35 to 795, with an average of 257. The average ratio of full-time faculty to medical students was 1:5.03 and ranged from 1:1.53 to 1:15.98. These numbers indicate that schools varied greatly in the number of full-time medical school faculty and the student faculty ratio. There were many vacancies at most schools. All 13 schools have a focus on faculty development using different strategies, including short and long courses such as Masters and PhDs, mentoring and faculty exchange, and research and medical education support to provide faculty with development programmes, stimulate medical research and ensure the quality of curricula. The challenges of the schools include shortage of faculty; internal and external brain drain; environmental factors, such as poor facilities; remuneration and incentives; and increase in the number of medical schools. Conclusion. Many of the MEPI schools have faculty shortages but are trying to tackle the problem using different useful strategies.

Prior

Since

Local

National

International

Grants obtained

Institutional

National

International

Reviewer: national/regional journals

Reviewer: international journals

Editorial board: national/regional journals

Promoting scholarship in SAFRI: Does it work? J Bezuidenhout,* J Frantz, J van Wyk, D Manning, F Cilliers, V Burch *jbez@sun.ac.za

Editorial board: international journals

Education-related responsibilities in your faculty

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385

Background. Ernest Boyer describes four types of scholarship: discovery, application, integration and teaching. Scholarship can be defined as ‘advancing or transforming knowledge in a discipline through the application of the scholar’s intellect in an informed, disciplined and creative manner’. It is demonstrated by peer-reviewed, publically disseminated output including publications, syllabi, assessment tools, teaching cases, webbased instructional materials, and curriculum change. The sub-Saharan FAIMER Regional Institute (SAFRI) programme, established in 2008, accepts applicants from the region and, implementing capacity development principles (leadership, project management, research methodology and educational methods), centred around an education innovation project to assist fellows to achieve at least an entry (minimum scholarly) level output of an abstract and a poster presentation at SAAHE. Objective. To compare the education-related scholarship output of applicants prior to and since entering the fellowship. Method. A survey was administered to all SAFRI fellows and faculty for the period 2008 - 2011 (three intakes), focusing on scholarly outputs in health professions education only. Results. Preliminary data analysis is presented in the form of a table, as the total for the cohort prior to and since entering the fellowship. Conclusion. Although a causal relationship between the increases in scholarly output since entering the fellowship will be difficult to prove, it is clear that there has been an increase, not only in the number, but also in the scope of scholarly outputs.

Awards

9 (2 international)

13 (4 international)

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Peer-reviewed publications Conference presentations

Workshops presented

Reviewer/editorial boards

PIQUE-ing an interest in curriculum development J Blitz,* H Conradie, N Kok, B B van Heerden, S van Schalkwyk *juliablitz@sun.ac.za Background. Most medical schools in South Africa have as their overall aim for undergraduate medical education, the preparation of graduates for internship. If we are to reach this aim, one of the ways to evaluate this would be to explore whether our graduates indeed feel able to do the things that we think they should, or could, be doing in their internship. Objective. To elicit the opinions of first-year interns who graduated from Stellenbosch University on the extent to which they felt that their undergraduate education had prepared them for internship. Method. The Preparedness for Internship Questionnaire (PIQUE) was designed based on Hill’s preparation for hospital practice questionnaire, with additional questions covering graduate attributes and the profile of the Stellenbosch doctor. Face validity was confirmed by a panel of faculty experts. The questionnaire asked the participant to respond to a series of statements preceded by ‘My undergraduate medical training prepared me to …’ with ‘fully’, ‘well’, ‘fairly well’, ‘little’ or ‘not at all’ prepared. It ended with open-ended questions, which allowed elaboration on other issues. In July

Abstracts 2012 an invitation to participate in the online survey was sent to all the 2011 Stellenbosch MB ChB graduates. Results. There was a 36% return rate. In general graduates felt that they had been well prepared for most mainstream clinical activities. However, there were also a number of areas in which respondents felt they could have been better prepared – largely in the areas of pharmacology, medico-legal work, minor surgery and the non-clinical tasks which an intern encounters. Conclusion. Using this questionnaire has highlighted areas needing attention within our curriculum. As many of these appear to be in nonclinical areas, it challenges us to look at how faculty can be developed to address these unmet educational needs of our undergraduate students. ‘A system that is constantly trying to shape you in a different way’: Students’ perspectives on being a good doctor C Naidu,* S Reid, V Burch *claudia.naidu@uct.ac.za Background. There is an ever-increasing awareness of the need for medical schools to train socially accountable health professionals. However, not much is known about students’ perceptions of what a socially accountable doctor is or does. Objective. This pilot study aimed to explore student’s perceptions of what a good doctor is as well as their understanding of a doctor’s accountability to society. Method. A purposive sample of medical students was invited to participate in this research via e-mail. Those who indicated interest and were available to attend were included in a focus group discussion. This data were supplemented by qualitative comments from a pilot questionnaire administered to all 4th-year medical students. Results. Ten students participated in focus group discussions and qualitative comments from another 20 students who had completed questionnaires were included in the analysis. Most students appreciated the psychosocial, patientcentred focus of medicine, and acknowledged their responsibility in improving access and quality of healthcare, particularly to those in need. However, many believed that engaging in ‘socially accountable’ activities are by choice rather than obligation, and felt that responsibilities needed to be prioritised, shared, and was dependent on the context and medical specialty. A few students were resistant to the idea that the medical profession was anything more than a career and felt that they are being unfairly expected to be self-sacrificing. Conclusion. The climate of the educational/training environment in which students learn is an important factor affecting the values and behaviours adopted. While the difficulties in teaching and evaluating social accountability are understood, it is imperative to develop tools and to generate knowledge of how students perceive and understand their roles and responsibilities, assess their behaviour and attitudes, and how this changes through the course of their training and practice. Medical students’ attitudes towards patient-centredness E Archer,* B B van Heerden, J Bezuidenhout *elizea@sun.ac.za Background. The doctor-patient relationship is fundamental to medical care, and several studies have shown that medical students’ attitudes in terms of this relationship deteriorate during their time in medical school.

The Patient Practitioner Orientation Scale (PPOS), an instrument that measures students’ patient-centred beliefs, was used in this study. Objective. To examine changes in the attitudes of medical students regarding patient-centredness as they progress through medical school as well as the validation of the PPOS as a measuring tool in our context. Method. Subsequent to validating the PPOS for the South African context in October 2011, medical students from year 1 to year 6 (N=1 127) completed the PPOS questionnaire in 2012. This was done as a cross-sectional survey. Results. The internal reliability of the questionnaire that seemed to be adequate with the pilot group (Cronbach’s alpha of 0.627 for caring and 0.67 for sharing) was very low in the final study (Cronbach’s alpha of 0.41 for caring and 0.57 for sharing ); therefore interpretations from the questionnaire should be made with caution. However, the mean score of the PPOS was much lower for this cohort of medical students compared with some other studies that were done in the rest of the world. Suggestions for such low scores could be that the scale should rather be used in qualified doctors as opposed to medical students. Other issues that need to be considered are the diversity of our student population, the definition of patient-centred care in our context as well as the interpretation of the PPOS questions. Conclusion. Even when making use of existing well-published questionnaires, the reliability scores still need to be considered. There seems to be a need for a reliable tool to measure patient-centredness in undergraduate medical students. Essential steps in the management of obstetrics emergencies (ESMOE) N Moran,* J Moodley, M Khan, N Nadesan-Reddy, M Muzigaba *morann2@ukzn.ac.za Background. In South Africa the current Saving Mothers report highlights the contribution of preventable causes to maternal deaths. In an effort to reduce such deaths, the Essential Steps in the Management of Obstetric Emergencies (ESMOE) was developed by a team of specialists. Objective. To train all midwives and doctors in all state facilities in KZN in ESMOE. Method. The programme consists of 12 modules of 90 minutes duration covering a range of topics including obstructed labour and maternal and neonatal resuscitation. The current model is a centrally run workshop over three days. Each individual module is facilitated by an expert who oversees small groups of trainees. A short lecture, skills demonstration, video, skills practice on a mannequin and role play (fire drills) all constitute a module. A ‘train the trainer’ approach has been adopted with master trainers then tasked with training others at their healthcare facilities. Relevant training material to do this is provided at the workshop. Results. Eight ‘train the trainer’ workshops have been conducted to date, with 190 doctors and nurses trained. Every hospital in KZN, several CHC/ MOUS and every district clinical specialist team (DCST) now has master trainers. Fire drills have been commenced by the DCST at local sites but have yet to be evaluated. Further evaluation of training by the master trainers at facility level is required. A partnership with the Department of Health has been forged to facilitate expansion of training. Conclusion. The ESMOE programme is ultimately aimed at reducing preventable maternal deaths; the impact of the training however is difficult to assess and still requires evaluation.

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Abstracts The transformation of health professions education in South Africa B B van Heerden,* V Burch , M de Villiers, S Reid, S van Schalkwyk *bbvh@ sun.ac.za Background. The global impact of work published by the Lancet Commission (2010), the Royal College of Physicians and Surgeons of Canada (CanMEDS), Boelen and Woollard, THEnet and others on the future education of health professionals cannot be ignored. In South Africa, several organisations have embraced international recommendations and are actively working towards transforming health sciences education and training programmes. Objective. To describe some of the current national initiatives aimed at transforming health professions education in South Africa with a view to informing further work in this regard. Method. In 2011 the Undergraduate Education and Training (UET) sub-committee of the Medical and Dental Professions Board (MDB) embarked on a strategic planning process to ensure that global and national recommendations regarding transformative learning, interdependence in education, graduate attributes and social accountability are used to guide the revision of health sciences education and accreditation processes in South Africa. To date a number of national workshops, including representatives from higher training institutions and the Collaboration for Health Equity through Education and Research (CHEER), have been held to plan the way forward. Other important national transformative initiatives include the Medical Education Partnership Initiative (MEPI), work done by the Academy of Science for South Africa (ASSAf), CHEER and others. Results. A number of processes are underway and some have produced strategic planning documents, peer review processes, research proposals and projects. Institutional conversations are increasingly characterised by a discourse of change. Specific desired outcomes are: institutions that are socially accountable; faculty who are role models of responsible practice; students who demonstrate social responsibility; graduates who are appropriately skilled for the South African context; and graduates with attitudes of commitment to service. Conclusion. Several national initiatives, focused on transforming health professions education in South Africa, are in place. Careful co-ordination of these processes, as well as government involvement, are prerequisites for success. Mentoring as social practice C Oltmann* *c.oltmann@ru.ac.za Background. Mentoring has been defined and described in many ways because there is no ‘one size fits all’ model. Every mentoring programme has to be designed to meet the needs of the mentees. Mentors and mentees form a relationship and together address the issues that the mentee deems as ‘real’. In the Faculty of Pharmacy at Rhodes University we identified the role of mentoring as a strategy for success. Mentees benefited directly from the mentoring process and mentors transformed as they constructed mentoring. Objective. To determine how mentors constructed mentoring as social practice. Method. In trying to determine how mentors constructed mentoring I had to do more than just describe mentoring because social mechanisms

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are not readily observable; they require theory and abstraction. I therefore used critical realism as my meta-theory, and discourse analysis as the methodology. I interviewed mentors, and analysed field notes of meetings, mentors’ journals, and evaluation data – using the NVivo® software program. Results. This research suggests that mentoring is about understanding, empathising, guiding, helping, and providing a shared space that is safe. Discourse analysis suggests that mentors require specific knowledge, that mentoring is about social relations and social identities, and that it is important not to abuse the power relations that are at play. Conclusion. The strategies that mentors employed changed as the mentors mentored. Mentors help make hidden rules and conventions overt during the mentoring process. The epistemological value of physics in medical rescue education and practice: Toward a transformative emergency medical rescue curriculum N Naidoo, L Christopher, M Marais, J Bosman* *naidoon@cput.ac.za Background. Physics is fundamental to most natural sciences. The rationale behind the medical rescue content of the Bachelor of Emergency Medical Care qualification is poorly defined. Medical rescue education in South Africa would benefit from contribution to its horizontal and vertical discourse and inform the academic level description and NQF alignment. Objective. To document the principles of physics implicit in the medical rescue curriculum, its implementation and its practice. Conceptual/ theoretical physics is critically appraised for alignment or misalignment in the medical rescue curriculum. Finally, recommendations of specific theories/principles of physics that may have implications and applications for medical rescue education and practice will be made. Method. Multiple qualitative approaches are employed. Document analysis is used to appraise linkages between physics and rescue inherent in the curricula. The Delphi technique is employed to reach expert consensus on the typology of rescue scenarios. Using process tracing, the practical components of medical rescue will be deconstructed for underpinning of physics principles. A criterion-referenced gap analysis will enable understanding of what principles and theories of physics are missing, desirable and fundamental to the goal of medical rescue paedagogy and practice. Results. There are no texts on medical rescue that address principles of physics and their application. This study informs evidence-informed rescue training and efficient rescue practice. Theories and ‘models of competence’ and ‘acting in context’ have relevance for knowledge integration of conceptual physics and medical rescue. This study problematises current medical rescue curricula, critically analyses the conceptual physics upon which medical rescue practice is predicated and provides a transformative approach to curriculum review. Conclusion. Critical reflection and inquiry into medical rescue practice is central to its professional growth. Impediments to learning include knowledge deficiencies and fragmentation, irreconcilable ontologies and pedagogic malpractice. Curricula transformation is preceded and proceeded by interrogating explanatory deficiencies and foundational prerequisite knowledge.

Abstracts Use of isiZulu videos as a teaching aid in clinical communication teaching in the College of Health Sciences P Diab, M Matthews,* R Gokool *matthewsm@ukzn.ac.za Background. The use of the Calgary-Cambridge guide in teaching communication skills to medical students is widely used. It has been debated whether such a guide is relevant and useful in multicultural societies. The University of KwaZulu-Natal finds itself in such a multicultural society with the challenge of equipping students to communicate with patients from different language and cultural backgrounds. Objective. To equip students with good isiZulu language and communication skills in order to improve student-patient communication and a patientcentred approach, and ultimately enhance retention of doctors in the public service. Method. Content topics and scenarios from each theme in the preclinical years were chosen. Transcripts were developed incorporating aspects such as language accuracy, clinical excellence and cultural sensitivity. Simulated patients trained in communication skills as well as doctors experienced in teaching communication skills and the Zulu language and culture acted in the videos. Editing and production of the videos were done using Windows Movie Maker. Results. The four theme-based videos that were developed provide basic and some extended vocabulary around the scenarios. The biomedical content included supports learning within the themes and highlights culturally sensitive topics. In addition to content, process skills in communication, especially those relevant to second-language Zulu speakers, are emphasised. Conclusion. The development of such videos is a unique and versatile tool that can be utilised in a variety of ways to achieve many different learning outcomes. The use of the videos fills a gap in communication which is vital to bridge language and cultural divides. The videos can be further developed to include a wider range of topics, with extended vocabulary and content. The potential exists for developing content for specialist disciplines and other health professions. Establishing an online short-course in clinical immunology L Walter,* E Monika *debbie@sun.ac.za Background. A one-month practical rotation for pathology registrars in the Immunology Unit NHLS Tygerberg (Division of Medical Microbiology) was initiated upon their request. In order to address a perceived knowledge gap in applied immunology as reported by the students, we developed an assisted on-line self-study course. Objective. To assess studentsâ&#x20AC;&#x2122; perceptions on the use of the on-line course and design and plan improvements based on student feedback and observations. Method. Structured interviews were applied by an independent third-party observer before and after completion of the self-study course. Student progress was tracked on the learning management system (LMS). Results. In the pre-interviews the students confirmed the impression of shortcomings of immunology teaching in undergraduate training and indicated willingness for self-directed learning on-line. In the post-interviews it emerged that, although students perceived the course as helpful, they did not indicate that their applied clinical immunology knowledge had improved significantly, with comments on the need for more clinical applicability. It

was noticed on tracking that almost half the students did not make use of the course, interpreted as lack of motivation. Some students reported difficulty in accessing the LMS from within their clinical setting. Based on these findings, the course was re-designed. Clinical cases and pointers to clinical applications were included. Copyrighted content was removed to allow all materials to be freely downloadable and usable off-line as well. The course was also given a more formal standing by converting it into a certified short-course, to provide more incentive to partake and complete. The immunology certificate can in future be included in the clinical portfolio. Conclusion. When designing an immunology on-line course, the material content for clinical registrars requires significant clinical applicability for motivation to partake in and finish the course. Our new short-course in clinical immunology is aimed to address these for the future. An assessment of University of Zimbabwe first-year medical studentsâ&#x20AC;&#x2122; experience with information communication technology (ICT) V Tagwira,* J Frantz *vjtagwira@yahoo.co.uk Background. It is universally acknowledged that the education of undergraduate medical students will be enhanced through the use of computer-assisted learning. Before designing a programme that serves local studentsâ&#x20AC;&#x2122; requirements best, there is a need to establish their access to and experience with ICT. Objective. To determine the level of ICT experience that first-year University of Zimbabwe medical students have, and the ICT resources that they currently have access to. It also explored their views on integration of ICT into medical education. Method. A cross-sectional descriptive study was performed using a selfadministered questionnaire that gathered quantitative and qualitative data. The survey population included all first-year medical students (N=286) two months into their degree programme. Results. A total of 120 students completed and submitted the questionnaire (42% response rate). Almost 12% (n=14) owned a desktop computer, 91.7% (n=110) owned a laptop, and 77.5% (n=93) owned an internet-enabled cellphone. All students owned at least one of the devices. Computer skills and experience with application software and the internet varied from no skills to advanced skills, with at least 54% (n=45) reporting basic skills, 42% (n=35) reporting intermediate skills, and 18% (n=15) reporting advanced skills. Generally, students felt that there should be greater incorporation of ICT and web-based tasks into their learning. Some students wanted to learn more about the internet and indicated that internet and social networking sites could be used to improve their communication with lecturers. Conclusion. Most of the first-year medical students at the University of Zimbabwe have a foundation of ICT access and skills on which effective use of information and communication technology in medical education can be constructed. Understanding the skills that medical students have regarding ICT use can possibly influence how educators incorporate ICT into medical education. Implementation of a podcasting website for undergraduate students W Liebrich,* L Khoury, S Rajah, D Pinetown, S Walsh *liebrich@sun.ac.za Background. We started podcasting lectures for the MB ChB II course in 2012 (see presentation by Steve Walsh). This has since been extended to

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Abstracts all MB ChB courses. These podcasts were initially uploaded onto various modules of our learning management system for students to view and download. Objective. To allow medical students and staff access to all podcasts of all modules of the MB ChB curriculum at all times. To this aim we implemented an access-controlled podcasting website in 2013. Method. A podcasting site was developed using the DotNetNuke Web Content Management Platform as well as Gallery Server Pro. Results. The podcasting site allows staff and students password-controlled access to all undergraduate lectures recorded so far. These include at this stage the lecture blocks Circulatory System, Clinical Pharmacology, Digestive System, Endocrine System, Haematological System, Health Management, Intro to Clinical Medicine 2, Musculoskeletal System, Neuroscience, Reproductive System, Respiratory System, and Urogenital System. Every podcast page contains a Treeview menu, but users can also click on the desired album to see its contents. The entire gallery can be searched for keywords contained in the lecture title. Entire lecture blocks or single podcasts can be downloaded. The website also gives background information, instructions, and a contact page with a feedback form. Facebook and twitter links are provided. Conclusion. The podcasting effort at the Faculty of Medicine and Health Sciences at Stellenbosch University has so far been perceived by the students as a resounding success. We are eagerly awaiting feedback from users on our new podcasting website. SAFRI and capacity building in health professions education J Bezuidenhout,* J Frantz, V Burch *jbez@sun.ac.za Background. Capacity building in health professions education has been identified as a need in Africa. The sub-Saharan FAIMER Regional Institute (SAFRI) programme, established in 2008, accepts applicants from subSaharan Africa and incorporates all of the capacity development principles. This programme focuses on leadership development, education methods, research methods, and implementing an education innovation project. This allows the fellows to apply what they learn in the context of an innovation project in their home institution. Scholarly outputs linked to this project include an abstract, a poster presentation and an paper. Objective. To demonstrate the reach and capacity building impact of the programme in Africa and the type of education innovation project completed. Method. A document analysis for the period 2008 - 2012 was conducted using the SAFRI poster presentation abstract booklet. Data were analysed by two reviewers and reported descriptively. Results. The SAFRI programme has reached 13 countries in Africa with a total of 75 participants. Participants were from a range of disciplines, including medicine (40), nursing (11), physiotherapy (7) and dentistry (4). The project emphasis was primarily on undergraduate programmes, with the study population usually undergraduate students (25 projects) and/or faculty (26 projects). Forty-two projects included a situational analysis or needs assessment, 21 focused on programme impact and evaluation, and 9 on curriculum development. Seventeen of the 75 projects concentrated on capacity building needs or interventions and faculty evaluation. A third of the projects had a community-based focus.

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Conclusion. In only 4 years, SAFRI capacity development initiative in Africa has already established a broad geographical footprint with multiprofessional representation and a range of education projects. An evaluation of students’ perceptions of learning in clinical learning centres based at district hospitals S Memon, J M Louw, M Bac, J F M Hugo, W N Rauf* *nisa.rauf@up.ac.za Background. The Department of Family Medicine of the University of Pretoria started a new 3-year course for mid-level medical healthcare workers in 2009. Most of their training takes place at 17 mostly rural district hospitals in the Mpumalanga and Gauteng provinces. Objective. To measure BCMP II and III students’ satisfaction with learning opportunities and their involvement in learning and to assess the functionality of rural clinical learning centres in district hospitals. Method. In 2010 and 2011 a survey was done using the Med-Ed IQ questionnaire. Results. Most students were satisfied with the learning environment and their preceptors as well as learning opportunities in all clinical learning centres. However, final-year students (group 2) were least satisfied with their involvement and they seem to be keen to assume greater responsibility in the care of patients’ with psychosocial and complicated problems. Conclusion. On the basis of this feedback from the students, important information was obtained and specific interventions were done which improved the learning environment of the Clinical Learning Centres. The students desired more learner involvement and participation in patient care, with a shared responsibility. Student feedback is very important to assess functionality of teaching platform and improve the learning environment. Students should be maximally involved in learning and patient care. Mapping transformation indicators in allied health sciences education at the University of Cape Town, South Africa – 10 years later (2001 - 2011) S L Amosun,* N Hartman *seyi.amosun@uct.ac.za Background. A five-year (2002 - 2006) operational plan was developed for the transformation of allied health sciences education in the Department of Health and Rehabilitation Sciences as part of the transformation process in the Faculty of Health Sciences, University of Cape Town. Objective. To carry out a preliminary review of the change processes that have taken place in education, research, and capacity development after the implementation of the operational plan. Method. Two documents – the annual Faculty of Health Sciences Handbook and the Research Reports – from 2002 to 2010, were perused, and the contents analysed descriptively. Results. Within the first four years after the implementation of the operational plan, the preliminary outcomes in undergraduate education revealed a widening of access to students, the modularisation of curricula, support for academically under-prepared students, expansion of the teaching platforms in service learning, and development of new multidisciplinary modules. New postgraduate programmes were also developed. The output in postgraduate education and research publication was low, but the proportion of academic staff with doctoral qualifications increased from 16.7% in 2002 to 46.6% in 2010.

Abstracts Conclusion. Since all the key purposes of the operation plan are yet to be achieved, the evaluation of the outcomes of the transformation process in the Department should be on-going. Current challenges in clinical teaching: A situational analysis for evidence-based change Z Gebremichael,* R Weiss *zerihunet@yahoo.com Background. In the past few years the medical student intake at Hawassa University has quadrupled, while human and material resources have not increased proportionately. A newly established Health Professions Education Unit (HPEU) has been tasked with addressing the educational challenges this situation creates. Objective. To identify gaps and challenges that the new HPEU must address to improve the quality of medical education. Method. A survey using a five-point Likert scale (1 being lowest rating and 5 highest) collected students’ opinions about current clinical teaching, learning and assessment practices. Four focus group discussions also gave instructors in each department opportunities to provide qualitative feedback on the same issues. Results. A total of 137 questionnaires were returned; 34 surgery, 32 internal medicine, 37 paediatrics and 34 gynaecology. The mean values for the summated scales are <3 for almost all thematic areas. The lowest means for all four departments surveyed were for co-ordination between departments and assessment methods. Students’ ratings were also unsatisfactory for instructional skills, course relevance and organisation, specific instructional situations, hospital teaching activities and professional ethics and attitudes. The major findings from faculty focus group discussions in four departments are: • training needs at subspecialty level and medical education for staff • inadequate practical exposure for students • lack of innovative and purpose assessment methods • inadequate infrastructure to handle large numbers of students • problems linked to student interest, attendance and discipline • loose interdepartmental co-ordination • lack of appropriate orientation and advice for students • need for curriculum revision. Conclusion. The participatory, dual approach of this study enabled both students and faculty to provide valuable inputs that will inform and guide the future work of HPEU in addressing the identified issues, and set the stage for implementing collaborative solutions. Technology as a tool to develop a community health model E Meyer,* S Stolz, J van den Heever *ellenoremeyer@hotmail.com Background. The presentation describes a case study of a community health model that was developed and piloted at an academic service learning clinic in partnership with the South African Department of Health. Within the health context of developing countries there is a need for an e-Health model that is contextually appropriate and supportive of national and international health information management. Objective. To strategise, innovate and implement a collaborative care model strengthened by available technological resources that would improve the

health and social status of a struggling community. To develop a collaborative care model by using technology as a tool that could practically demonstrate the multidisciplinary team’s participation in service learning. This framework would inform sharing of patient health and social information, synergising of resources and future community development plans. Method. The question posed was explored by means of a multidisciplinary literature review and a restricted narrative enquiry of the experiences of the healthcare team. The 5 Cs e-Health framework for developing countries was applied together with the Human Resources for Health 2030 strategy. Results. The World Health Organization identified five key elements of effective primary health care. In practice this implies reducing social disparities and services orientated around people’s needs, including the integration of health into all sectors and the pursuit of collaborative care with increased stakeholder participation. The Daspoort case study indicates that an e-Health framework could develop and strengthen a collaborative team approach to integrate healthcare among community role players and increase community involvement to improve the health of society. Conclusion. Technology as a tool could unlock community development by strengthening collaboration via the delivery of information to enable better individual, stakeholder and community decision-making in health and social issues. Getting answers that you can trust – issues in questionnaire design W McMillan* *wmcmillan@uwc.ac.za Background. Surveys are commonly used in higher education to gather facts, opinions and attitudes. While survey research has a long history, literature suggests that survey methods are not always well understood or properly executed – especially in educational research. Errors in study design, sampling techniques, and instrument design can undermine confidence in the survey results. This poster offers theoretical insights into valid and reliable survey research in health sciences education. Objective. To introduce the basic elements of survey research relevant to education and identify common problems in survey research. A study of senior students’ experiences of alienation and engagement in a faculty of dentistry in South Africa is used to contextualise the insights. Method. The literature was reviewed for texts related to survey research methods. Particular attention was paid to accessing relevant literature from health sciences education. Results. The literature highlights the importance of: clearly defining the research problem/question, the purpose of the study and the associated research questions prior to questionnaire design • clearly identifying the aspects to be surveyed, and identifying the associated variables • compiling relevant questions associated with the variables • writing ‘good’ questions that are clear and specific • auditing the survey for completeness related to the information desired • selecting scales appropriate to the type of question posed • appropriate and defensible sample selection • piloting the questionnaire to pre-test the survey questions. The poster uses the alienation and engagement student survey to illustrate these key aspects of study design. Conclusion. Rigour in survey planning, construction and implementation are essential to ensure valid and reliable results. The credibility of educational

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Abstracts research depends on the alignment of all aspects of the survey. Only then can the significance of findings be claimed, and the applicability of findings to classrooms and clinical contexts be justified. A review of University of the Witwatersrand medical students’ communitybased health promotion service learning projects in South Africa G Mothoagae,* J Irlam, D Prozesky, T Hlungwani *gaolatlhe.mothoagae@wits.ac.za Background. Third- and fourth-year Graduate Entry Medical Programme (GEMP) students at the University of the Witwatersrand undertake community-based service learning (SL) projects. Working with trained facilitators, students are required to identify a priority health problem in the community, and then plan and implement an appropriate project to address the problem. At the end, group presentations are conducted for assessment. Objective. To review past SL projects that have been implemented by GEMP 1 and 2 students in order to inform the future planning and conduct of the SL programme in the faculty. Method. A document review of all available PowerPoint presentations for projects implemented from 2006 to 2011 was undertaken, employing content analysis. Results. Of approximately 286 projects completed, 183 documents were available for review. Of the implemented projects, 38.8% were clinic based and 28.4% done in the inner city region of the City of Johannesburg municipality. The projects covered a wide range of health issues employing mainly basic health promotion strategies such as health education and distribution of educational posters and pamphlets. Four themes on students’ perceptions of the educational worth of the projects were identified: theory comes alive, improved knowledge and understanding of communities and their needs, appreciating the expanded role of a doctor, and personal growth. Challenges reported by the students included administrative shortfalls, poor communication and facilitation, lack of students’ participation in project selection and prioritisation as well as limited time allocated to work on the projects. Conclusion. These findings indicate that students benefit from participating in the project. However, future planning and co-ordination of these projects need to address the identified loopholes based on students’ concerns. It is recommended that more attention be paid to strengthening the administrative and supervision aspects, making efforts to involve students properly in project selection, improving communication between the university and the community facilitators, and reviewing placement duration. An evaluation of an HIV/AIDS peer education programme at a higher education institution in the Western Cape H Vember* *vemberh@cput.ac.za Background. Education seems to be one of the most powerful weapons to fight the HIV/AIDS pandemic in South Africa; hence it is expected of higher education institutions (HEIs) to respond to this problem in a meaningful manner. Higher Education HIV and AIDS Programme (HEAIDS) took the initiative to bring all role players in HEIs together to devise plans to deal with the pandemic. Despite the fact that 22 of the 23 HEIs surveyed by HEAIDS in 2008 were engaged in peer education training programmes, none of them monitored or evaluated these programmes.

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Objective. To evaluate and establish the influence of a peer education programme among students at a selected HEI in the Western Cape. Method. An evaluation research design was employed, using a mixed methods approach to collect data. Quantitative data were collected by means of a questionaire. Qualitative data were collected by means of personal interviews with staff and focus group interviews with student groups. A Logic Model was developed that assisted with the evaluation design. Results. The quantitative data revealed that more work needs to be done with regard to behaviour change among peer educators. It was clear from the data that knowledge does not lead to behaviour change. An example is as follows: despite the fact that students received the same information with regard to safer sex practices, 80% use condoms, but 20% still do not use condoms, and 6% still have multiple partners. However, in this study, the qualitative data showed that peer educators need to develop more skills to empower themselves to facilitate workshops and to enhance their communication skills. A strong emphasis should also be placed on reflection within the programmes. Conclusion. If the lifespan of the peer education training programmes on HEIs is lengthened and more students are engaged in these programmes, it would have the potential to develop staff, students and communities into advocacy-orientated communities that would eventually challenge the HIV/ AIDS pandemic through united mobilised action. It is important that all peer education training programmes and interventions on all HEI campuses become part of a coherent, well-planned and strategic process to include HIV/AIDS and STI education meaningfully across the curriculum. Knowledge of community-oriented primary care among heads of department at Makerere University College of Health Sciences K I Besigye,* A Barnard *kibesigye@yahoo.co.uk Background. In 2003, Makerere University College of Health Sciences (MakCHS) introduced community-based education to achieve social accountability as one of its core values. A situation analysis of teaching and learning of medicine and nursing students done in 2010 showed that primary care competence was not adequately addressed by the current learning and teaching strategies. Community-oriented primary care (COPC) training has been documented as a viable educational strategy to improve graduates’ competence in primary care. Objective. To establish COPC knowledge among heads of department (HoDs) at MakCHS and their willingness to train medical students in COPC as an additional strategy to community-based education to improve competence in primary care. Method. This was an exploratory qualitative study using a purposive sample of 10 HoDs at MakCHS. The interviews were transcribed verbatim, transcripts were reviewed and a manual qualitative analysis was performed revealing the emerging themes and sub-themes. Data saturation was reached after 10 interviews. Results. All HoDs knew the concepts of COPC like students knowing their practice communities and being able to involve communities in their health affairs. All respondents mentioned that community priority health problems should be identified and that students should be able to identify the underserved and disadvantaged populations in communities. All respondents mentioned that students acquire these skills during their community placements. Only one respondent had ever heard the term COPC, but all were willing to train students in COPC.

Abstracts Conclusion. HoDs at MakCHS have knowledge of COPC and are willing to train students in COPC. There is a mismatch between the COPC knowledge and understanding of COPC training for medical students as there is a belief that placing students in the community is equal to community-oriented medical education. Staff need COPC training to transform communitybased education at MakCHS to community-oriented medical education to improve students’ primary care competence. Medical students and social accountability C Gordon* *chivaugn@gmail.com Background. Social accountability is a prerequisite for all faculties of health sciences. There is considerable literature acknowledging this and encouraging institutions to increase their practical efforts to implement change that will produce socially responsive graduates. Lack of exposure to ‘coal face’ or primary healthcare situations may be restricting students’ growth in developing greater social awareness, and one way to accomplish a change to greater social responsiveness could be through exposure of undergraduates to student-run volunteer clinics. These clinics reflect the shift in students’ training from hospital based to community based as well as epitomising students’ taking responsibility for their own learning. Objective. The University of Cape Town is exploring students’ attitudes to student volunteer-run, after-hours clinics, which take place in underserviced and disadvantaged areas. Method. A survey is being undertaken to gauge the motivations of students who volunteer to attend the Students Health and Welfare Community Organisations (SHAWCO) clinics. These clinics take place in several informal settlements around Cape Town. Focus groups will further explore purposely selected students’ attitudes to this constructivist, and potentially transformative, learning experience. Results. The results of the survey of students’ attitudes and perceptions of their personal growth and clinical acumen gained from these clinical experiences will be presented in quantitative and qualitative format. The pilot study indicates a considerable growth in altruistic pride in attendance at the clinics. Conclusion. Undergraduates who volunteer to serve in clinics set up by their fellow students find the experience formative, and that time spent in this endeavour fulfils a significant role in promoting social accountability in their education. Student-run clinics have the potential to promote social accountability in the medical curriculum. A curriculum for the community M S Mogodi,* J Blitz *mpho910@gmail.com Background. When the University of Botswana (UB) opened the country’s first School of Medicine (SOM) in 2009, the decision was made that medical students should be introduced to the community from the onset of their medical training. Objective. To guide the UB SOM Public Health Medicine (PHM) unit to come up with a curriculum for first- and second-year medical students’ community placement module. Method. Qualitative research was conducted following ethical clearance. Purposively selected key informant interviews were conducted among

education experts, health services experts and leaders at the UB’s Faculty of Health Sciences. A semi-structured interview guide was used to elicit the respondents’ understanding and suggestions regarding a rural placement curriculum design. Recorded data were transcribed and coded. Results. The following themes were identified as required elements of a community placement curriculum: curriculum design that includes spiralling outcomes, clearly aligned outcomes, active learning, integrated multiple forms of assessment, and contextualised learning; course elements that entail community needs assessment, intervention and systems thinking; guiding values that support social accountability, holistic health definition, problem-based learning and systems thinking; logistics to be considered for a rural placement programme including transport, accommodation, nationwide student placement and duration of the placement. In general, there is agreement that the community placement programme should be guided by the philosophy of social accountability. There is continuing support for the UB SOM medical students to have community placements from the onset of their medical training. Conclusion. In order for health professionals to make a difference in their communities they need to work in communities they will serve and find long-lasting solutions to the community’s needs. Conducting key informant interviews on the issue of community placement can provide valuable input for the development of a socially accountable community placement curriculum, and provide the groundwork for ensuring co-operation in its implementation. What’s in the knitting? C Engelbrecht* *engelbrechtc@ukzn.ac.za Background. Higher education in the health professions has an important role to play in affecting the community’s health and wellness. Education is not merely a tool for personal development and self-actualisation. By participating in community-based education programmes, health educators and their students are providing services to the community that might not have been available owing to lack of resources, assisting a process of transformation in the community towards healing and wellness. Kaethe Weingarten declared that all of us are subjected to common shock as a result of witnessing violent and violating acts in everyday life. To raise awareness and healing from common shock, Weingarten recommended acknowledgement and planned action. She called this compassionate witnessing. Objective. A knitting project was used to develop informal social support and compassionate witnessing and the experiences of participating students and community members were explored. Method. Students in the B. Nursing programme at the University of KwaZulu-Natal were doing mental health promotion in a nearby community known for its violent and criminal acts in the past. A content analysis of two focus groups was done, where the community and student participants were invited to share their experiences and opinions of the project. Results. The results were compared with the literature in this field and will be discussed with the audience. By knitting teddy bears in a group, women have the opportunity to stand up against the abuse and violence they are witnessing directly or indirectly. The group provides opportunities for conversations about these acts. As relationships are kindled, an informal compassionate witnessing community is developed. Nursing students learn

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Abstracts how to listen and facilitate this conversation and compassionate witnessing. Conclusion. By knitting teddy bears in a trauma care project, community members get an opportunity to ‘do hope’ as a transforming compassionate witnessing act. Let us knit! An interprofessional education project – a model for learning in context H Talberg,* P Gretschel, F Walters *heather.talberg@uct.ac.za Background. With rehabilitation being seen as an integral component of service delivery plans within the South African healthcare context, promoting the presence and role of rehabilitation professionals in both district and primary healthcare settings has become a necessity. With one of the key mandates of district level service being the of development of a multiprofessional approach to client care, higher education institutions have looked at ways to better prepare their students for this infrastructure. This involves exposing undergraduates to this type of work environment and approach. One such initiative is the inter-professional student learning site at Vredenburg in the Saldanha Bay sub-district of the Western Cape. Here, health and rehabilitation students from the University of Cape Town’s Health Sciences Faculty, representing the disciplines of audiology, occupational therapy, physiotherapy and speech and language therapy are placed together to engage in practice learning. Vredenburg is a semi-rural area in which a shortage of health professionals, limited access to specialist services and a broad client population make it an authentic context in which inter-professional practice can be facilitated. While such practice is strongly encouraged as an effective way in which the complex health needs of individuals and communities can be addressed, the structural and attitudinal barriers to inter-professional practice are well documented. Method. This paper describes a pilot course in which inter-professional practice has been extended beyond paper case discussion to practise contexts where students have worked collaboratively with vulnerable children in the context of their home and community. Results and Conclusion. Provisional findings describing the students’ learning about their own and other health professionals’ contributions to care within an interdisciplinary context will be presented, as well as their suggestions of how inter-professional practice can be facilitated in practice learning contexts. Views of student nurses regarding implementation of case-based teaching and learning methodology at a higher education institution: A reflection on student perspectives N S Linda,* F M Daniels, L P Fakude, R R Modeste *nlinda@uwc.ac.za Background. The undergraduate nursing students` enrolments increased from 150 in 2003 to 300 in 2005 in the first year BNURS programme at the University of the Western Cape (UWC) based on a mandate from the Minister of Education regarding nursing education in the region. This resulted in three universities collaborating to offer the nursing programme. UWC had to respond to the changes and challenges, among others by reviewing the teaching and learning approaches used at the time, and ensuring more creative approaches that were current and relevant and, in view of large student numbers, would ensure that students’ learning was adequate and high-quality graduates would be produced. Case-

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based education methodology was selected as an overarching innovative teaching and learning approach at the School of Nursing at UWC. After more than six years CBE adoption and implementation at SON, its inherent value to teaching and learning had not been researched. A need was identified to establish what the experiences of the recipients of CBE are and whether or not it meets the purpose for which it was adopted. Objective. To establish what the studens’ experiences are with regard to the use of the CBE methodology for teaching and learning in large student classes. To establish whether or not the CBE method is of benefit to recipients Method. A qualitative research approach and case study design were used. Inclusion criteria were year 1 and 2 students registered in the BNURS programme at SON at UWC. Potential participants were purposely selected. The sample consisted of students in year 1 and 2 of the BNURS programme. Nursing module evaluations and portfolios were the data collection sources. Data were analysed using Tesch’s (1992) thematic analysis method. Results and Conclusion. These indicate that students have mixed experiences about CBE. Positive experiences include benefits such as growth in interpersonal skills, problem-solving skills, respect for each other, and teamwork. Participants’ negative experiences were challenges with learning process and content, which were overcome over time, and inappropriate distribution of time between theory and practical learning opportunities. Evaluation of the palliative training and palliative care provider visits at the University of Pretoria A Rautenbach,* M van Rooyen, E Meyer, A Reinbrech-Schütte *anita.rautenbach@up.ac.za Background. In 2011, four palliative training and hospice visits (PTHV) were introduced to the fourth-year medical curriculum. The programme was adapted in 2012 to address the challenges identified below: • Developing an understanding of hospice in terms of facilities, patients and services. • Providing opportunity to experience multidisciplinary, holistic management in various settings. • Developing a consultation approach to the patient with a terminal disease. • Developing an understanding of pain and symptom management. • Developing life skills. • Creating awareness of related ethical and professional challenges. Objective. • To evaluate the impact of PTHV on students in terms of personal, academic and professional growth. • To evaluate the opportunities to experience the holistic, multidisciplinary management of patients and to map the differences in sites. • To evaluate the impact of the changed programme. Method. This is a descriptive, qualitative study with a questionnaire to students, hospices and palliative care providers. Feedback questionnaires are individually scrutinised for themes by researchers and then compared until consensus is reached. This will continue until saturation is achieved. Results. Preliminary results show that the new introductory session made a huge difference in terms of the students’ perceptions of their own readiness for the visit. Although the programmes and activities at the various sites differ, the potential for learning is universal and transferable. It seems that the challenge that death and dying pose to the students is a good catalysing agent for personal and professional reflection and growth.

Abstracts Conclusion. Palliative care exposure is an excellent platform to experience multidisciplinary management of a patient, as well as being exposed to the challenges of dealing with a family. Good support and preparation is necessary. This is a learning and growth experience for students. Assessing a directed PBL course – pitfalls and solution J Wright* *john.wright@mopipi.ub.bw Background. The University of Botswana School of Medicine MB BS course uses a form of directed problem-based learning (PBL) in its two pre-clinical years. Some outline lectures, plus practical and workshop classes, support student learning in PBL. A challenge of this system is to ensure that students regard the support class framework as a way of guiding their PBL, and not as the backbone of the course. Objective. The concern was that learning around PBL cases and not just learning in formal classes should be assessed in examinations, but standard MCQ- and EMQ-type questions can usually be identified as deriving from a particular support class. The aim was to re-focus the exams on PBL cases. Method. We have devised a short-answer format in which a clinical scenario derived directly from a PBL case that the students have studied leads to a series of questions. The subject matter of these questions is intentionally diverse and can range from anatomy, through physiology, pathology and pharmacology to clinical skills and public health arising from the same root scenario. Examples will be presented. Student feedback was collected after every exam and included questions about the way the test balanced PBL and lecture material. Results. An analysis will be presented and correlated with the introduction of the case-based questions, which now comprise up to about 50% of the marks of each examination. Conclusion. To avoid a directed PBL course being viewed by students as lecture based, it is important that PBL is tested in an obvious way. One way of doing this is to use scenario-based questions that require multi-subjectbased answers. It will further reinforce the importance of PBL if these derive obviously from such cases. Developing critical thinking skills through radiography service learning R W Botha,* J Bezuidenhout, M M Nel *rbotha@cut.ac.za Background. The literature indicates that service learning assists in the development of critical thinking skills of students engaged in communitybased educational experiences, where critical thinking is defined as a reasoning process that involves reflecting on ideas, actions and decisions. The development of students’ critical thinking skills is the only education that makes good citizens, as individuals educated in it are not easily coerced, but rather seek out and weigh evidence. It is also suggested that service learning helps students to develop as ‘traditional experts’ and as ‘expert learners’. Objective. To establish specifically whether service learning cultivates critical thinking in radiography students. Method. Radiography students were divided into five groups, each with their own identified community. Since radiography is a resource-based discipline, learners decided to concentrate on the dissemination of information related to mammography, ultrasound and bone densitometry. Each group prepared

and executed dramatised presentations. Radiography students (N=22) had to complete the Watson-Glaser critical thinking tool before and after the intervention. The results were averaged and compared to evaluate whether there was development of critical thinking skills or not. Results. The Watson-Glaser critical tool average for the pre-intervention was 75.98% and that of the post-intervention was 80.72%. For the deduction section of the tool it was 68.6% and 72.8%, respectively. For the interpretation section it was 79.46% and 96.6%, respectively. Conclusion. Overall, the difference in the preliminary results suggests that service learning does promote the development of critical thinking skills. Additionally, there is a definitive increase in interpretation and deduction skills among radiography students. Clinical training in the discipline of speech language pathology at UKZN: Establishing a balance between service and learning P Flack* *flackp@ukzn.ac.za Background. The discipline of speech language pathology (SLP), in line with the UKZN vision, mission and goals, has a strong focus on community engagement that is entrenched in the curriculum. In planning clinical modules, the discipline prioritises service or engagement in under-resourced contexts and/or under-served communities. Fourie (2008) suggests that different forms of community engagement activities include volunteerism, internships, experiential education, service learning, community outreach and research. This paper explores what is understood in the discipline of SLP as academic service learning (ASL), one of the ‘cluster’ of activities of community engagement. Objective. ASL brings together community service with teaching and learning in official credit-bearing modules. However, it has been recognised that service learning activities may not always result in learning goals being met where service provision becomes the primary goal (Furco, 1996). In this paper 10 clinical modules offered in the discipline of SLP are interrogated with a view to evaluating whether the focus on service compromises learning and vice versa. Method. Data are gathered through a modified version of Schumer’s assessment of the service learning tool, focus group interviews with staff and students and analysis of curriculum documents such as module guides. Results. These suggest that while it is important to establish a balance between service and learning in the professional programmes, the scales may tip in a particular direction as a result of context, of students’ level of competence and independence as well as community needs. Conclusion. While it is important to establish a balance between service and learning in the professional programmes, the scales may tip in a particular direction as a result of context, of students’ level of competence and independence as well as community needs. Perhaps a balance is not always necessary. The prevalence of burnout among emergency medical care students at the University of Johannesburg T Sibanda, C Stein* *cstein@uj.ac.za Background. Burnout has been identified as a cause of poor academic performance and an increase in attrition rate in medical students. The

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Abstracts Bachelor’s Degree in Emergency Medical Care (EMC) is a four-year qualification focusing on pre-hospital emergency care. In addition to academic work, students must complete a significant clinical learning component from year one and are often exposed to very challenging emergency cases during this time. Several studies have identified high levels of burnout among qualified paramedics. We thus hypothesised that the combination of a stressful clinical environment and the stresses of academic life may pose a significant risk of burnout to EMC students, which may in turn adversely affect their academic performance. Objective. To determine the prevalence of burnout, and whether a significant difference existed in burnout scores across the four academic years of study among students at the University of Johannesburg’s Department of Emergency Medical Care. Method. The Copenhagen Burnout Inventory (CBI) was used to assess levels of burnout in the personal, work-related and patient care-related categories. Students (N=93) were asked to complete a questionnaire based upon the CBI, but also containing a number of distractor questions. Burnout scores were calculated according to the CBI scoring method and these data were analysed descriptively. Mean differences in CBI scores over the four academic years of study were assessed using one-way analysis of variance. Results. In the first-year group, 35% of students had CBI scores ≥50 (the threshold for falling into the ‘total burnout’ category). Between 9% and 19% of students in the remaining academic years were found to fall into the total burnout category, with fourth year containing the greatest proportion and third year containing the smallest proportion. Personal burnout was found to be the greatest contributor to the students’ CBI scores in first, second and fourth year, while work-related burnout was the greatest contributor in third year. Patient care-related burnout was consistently observed to be the smallest contributor to CBI scores across all academic years. No significant difference was found in CBI scores over the four academic years of study. Conclusion. Although direct comparison with similar programmes is not possible owing to a lack of published data, the prevalence of total burnout appears to be fairly high, particularly in the first-year group. This result was unexpected, as we hypothesised that the prevalence of burnout would increase with years of academic progression in keeping with the greater academic complexity and responsibility faced by students. Results regarding the contribution of different categories of burnout to CBI scores were also contrary to our hypotheses. In particular, burnout arising from patient care (i.e. clinical learning) had the smallest contribution to total burnout, while personal burnout contributed the most. While we did not study the effect of burnout on academic performance, a negative effect is highly likely. A burnout monitoring or surveillance programme should be initiated in order to diagnose this problem early and bring about efficient referral to the appropriate support services. Recruiting rural-origin students to health sciences – a 1-year follow-up of top achievers at rural high schools in South Africa C Pfaff,* L F du Toit, I D Couper, N O Sondzaba *colinpfaff@yahoo.co.uk Background. South Africa has struggled to attract healthcare professionals to work in rural areas and evidence from many countries suggests that students from rural areas tend to return to rural areas for medical practice. As a result, there has been a call to increase the number of students from rural origin at medical schools.

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Objective. To evaluate the challenges students from rural areas face in accessing tertiary education. Method. From March to June 2009, a facilitator from Wits conducted a life skills and careers course as part of a project to identify suitable students for the health sciences bursary programme in rural high schools in North West Province. A total of 39 schools were invited to send the top Grade 12 achievers in maths and science to a 5-day programme. These students were then contacted by telephone after 12 months and a quantitative survey questionnaire was administered. Results. Of 158 students, 54 could be contacted one year later by telephone; 46 respondents (87%) could not follow through with their original plans for the year following the completion of their Grade 12, although 13 (24%) were studying at tertiary institutions with plans other than they had anticipated, mainly at colleges. Only 7 (13%) students were able to achieve their original plans of studying at a university. Nine (17%) of these top students failed Grade 12 and 27 (50%) respondents were at home and not doing anything. Reasons for not achieving initial plans were academic (44%), financial (30%) and logistic (26%). Thirteen out of 16 students who applied for financial aid received it. Information sent by the tertiary institution, career days and friends already at tertiary institution were the most commonly used sources of information to access financial aid. Career days, friends already at tertiary level and life orientation classes were the most common sources of help used in choosing which courses to study. Conclusion. A minority of top-achieving rural high school students are able to access tertiary institutions in South Africa, but many of those who are successful do access financial aid. As open days are an important source of information, universities would be advised to give more resources to these events. An interventional study: Assessing knowledge, attitudes and practices regarding Mycobacterium tuberculosis infection risk among health science students H van der Westhuizen,* K Kotze, H Narotam, B Willems, A Dramowski *15635317@sun.ac.za Background. South African healthcare workers are at increased risk of contracting tuberculosis (TB), and drug-resistant TB. health science students working in TB-endemic settings require knowledge of TB control measures to reduce their risk of occupationally acquired disease. Objective. To determine knowledge, attitudes and practices of health science students regarding Mycobacterium tuberculosis and to assess the impact of a structured intervention imparting knowledge and awareness of occupational TB risk and control measures. Method. A cross-sectional study of 327 Stellenbosch University and health science students using a pre- and post-intervention questionnaire. The intervention included personal accounts by medical professionals affected by drug-sensitive and -resistant TB and information on how to reduce occupational risk. Results. Students overestimated their risk of developing TB, but underestimated the mortality associated with the drug-resistant strains. Pre-intervention knowledge of using personal protective equipment (PPE) was poor, but was successfully improved by 20% post-intervention (0.575 v. 0.775 out of 1 (p=0.0000)). Reported practices at Tygerberg Hospital (TBH), Western Cape, showed that 62% (N=182) interacted once a week or more with patients who had defaulted on TB treatment. Only 8% reported that

Abstracts N95 masks were available daily, where needed (N=177). Natural ventilation and mechanical ventilation were reportedly not used/functional in clinical areas (60%, N=179 and 55%, N=164, respectively). Additional MDR TB control measures, such as airborne precaution signs and a ‘closed door’ policy for TB isolation rooms, were reported to be inadequately utilised. Conclusion. Health science students lacked knowledge of TB control measures and protective equipment while working in an environment with reportedly poor implementation of infection prevention measures. A structured educational intervention can effectively increase awareness and knowledge pertaining to occupational TB infection risk and control measures.

entertainment like movies (18% to 64%). Effect of drugs and smoking on academic activities was minimal (2%). However, students minimised the time spent on the distracting activities when their grades suffered. Conclusion. The academic programme at MMMC is packed with different activities. Avenues for entertainment are limited in the campus. It is but natural that students take refuge in playing online games and watching movies on their computers. It is a relief however, to know that students have stayed away from drugs and smoking. Nevertheless, some advice regarding time and resource management through the mentorship programme is in order to further better the academic performance of the students.

Impact of formative assessment on low achievers S R Kamath,* S Torke, A M Ciraj *surekharkamath@yahoo.com

A progress evaluation of extended degree programme (EDP) students at Stellenbosch University with the aim to determine the reasons for differences in performance in the years following on the EDP programme A J N Louw,* A Bawoodien, L Crous, G Young *ajnlouw@sun.ac.za

Background. It is a well-known fact that assessment is an integral part of the curriculum. Students seldom have adequate information on the core areas of the curriculum that need detailed study and the nice-to-know areas of the curriculum. So we must ensure that students know the performance expected of them, and the standards against which they will be evaluated. To meet the above-mentioned needs, frequent feedback for enhancing the student learning process should be included among low achievers. Objective. To enhance the performance of weaker students in the first year medical students in the subject of physiology. Method. Based on the performance of the students at the end of first semester weaker students were identified and trained by remedial classes. Results. A total of 127 students were in the study group, 28 students were identified as weaker group. Of these students 17 (60.7%) were able to pass physiology. In spite of remedial activities the remaining 11 (40%) students were unsuccessful. The incorporation of formative assessment would help the students to reflect on their learning process and help them take adequate remedial measures with the help of faculty. Conclusion. By providing a timely feedback on the student learning process and effectively guiding students through the essential elements of learning, performance of students will be enhanced. Thus it is important to help low achievers in completing their medical course for serving the community. Distraction factors that affect the academic performance of students at the Melaka Manipal Medical College, Manipal, India M Roche* *mayaroche2011@gmail.com Background. Academic excellence is what every institution desires from its students. At Melaka Manipal Medical College, Manipal India, majority of the MBBS students hail from Malaysia with a smattering of students from other countries. In addition to living away from home for the first time, they are exposed to a new culture in India and possibly distracting surroundings. Objective. To study the general perception of students regarding the distraction factors that prevail in the student community and what survival strategies they have developed. Method. A questionnaire consisting of 9 items pertaining to the factors that distract students from academics was distributed to two batches of students, seniors (n=134) and juniors (n=92) of the MBBS programme. The results were analysed and expressed as a percentage. Results. Both the batches of students opined that the internet and online games were a major distraction factor (41% to 69%), followed by visual

Background. Students which are selected for the EDP programme generally do well during Phase 1 of the programme, but the phases following on Phase I are experienced as challenging with a number of these students experiencing academic problems. Faculty can react to this challenge by determining what could be done in the EDP programme to prepare these students adequately for the full academic programme following on Phase I. Objective. The unsuccessful progress of some EDP students in the consecutive years following the EDP programme necessitates a systematic investigation to be done to determine the factors contributing to the lack of progress of some of the students, as well as the factors contributing to the successful completion of the programme by their peers. Focused and systematic intervention could be launched if such factors could be identified. Method. A retrospective quantitative and qualitative study was done. The results and selection data of all EDP students since 2007 up to the most recent results (Nov. 2012) were analysed. Individual in-depth interviews were held with eighteen students – both successful and unsuccessful – in modules of Phase II. Interviews were also conducted with relevant Advisors of these students. Interviews were recorded and transcribed by an independent person. Data were thematically analysed. Data that were collected from examination results were used to invite students to participate in the interviews. Results. Five major areas were determined as to be the major problematic areas. The Academic and Social themes sound self-evident, but the specific factors in these themes provide faculty with food for thought to react upon. Other important themes were those of the psyche, residence, and finances. Conclusion. Scientific research is essential to facilitate the process of determining crucial factors influencing student success in an EDP programme. Assessment for learning: Facing the change, changing the face B Subramaniam* *barathi2021@gmail.com Background. Assessment and learning are intimately intertwined and often indistinguishable from one another. The new reforms introduced by FAIMER has brought assessment as a lever for educational reforms to the forefront and as an integral part of learning, not as a thing to be done in the last. Assessment has to be differentiated and understood in all its intricacy. It is becoming increasingly apparent to redefine assessment and its different approaches.

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Abstracts Objective. The study was done to identify the effect of combining assessment for learning with assessment as learning. Method. Sixty students of first year MBBS who consented for the study were enrolled. The students were bifurcated into two groups – Control and the Study Group. An environment was created in which students of the study group were exposed to learning purposes, learning outcomes, and were trained in peer assessment and self-assessment using success criteria to reinforce the assessors learning as well as to give constructive criticism, while the control group was not provided any such exposure. In both the groups’ assessment for learning was carried out as per the university guidelines. Results. The results show that the performance of study group is better when Assessment as Learning is combined with Assessment for learning. In addition, many nurturing effects of assessment as learning were also observed by the teachers who witnessed the overbrimming joy of the learners’ as they were not the passive receivers but active participants. Learners’ motivation and self-esteem apparently sloped high. Conclusion. Assessment for learning combined with Assessment as Learning significantly improves the assessment of learning. When adopted for the entire course, this will transform the perspective of formative assessment. The tiny steps travelled together can transform learners and learning. The AFEM REX: An innovative workplace-based assessment method for emergency care training in Africa H Geduld,* T Reynolds, V Burch *heikegeduld@yahoo.com Background. The African Federation for Emergency Medicine (AFEM) is a regional professional and academic organisation representing emergency care providers and trainers from over 20 countries. AFEM’s scientific agenda includes the development of emergency training programmes for a range of providers and settings. AFEM has developed a modular emergency care training programme for physicians and non-physicians who provide emergency care. Objective. To describe the development and piloting of an innovative workplace-based assessment method for the AFEM emergency care curriculum. Method. We conducted a review of existing workplace-based assessment tools used in the setting of medical training as well as a review of the more specific literature on emergency medicine shift-based feedback. Based on our findings, we developed a draft clinical evaluation tool and adapted it to the distinct constraints of the African emergency department work environment via a systematic consensus process. We subsequently conducted a feasibility pilot of the tool in two African emergency departments with post-graduate physician training programmes, and revised the tool to these results. Results. We present here the AFEM REX (Rapid Evaluation Exercise), an assessment method designed to be used in 5 minutes and focus on a single competency domain for each use. We present the results of our initial pilot study and the final version of the tool. Conclusion. The AFEM REX is a useful workplace based evaluation method suited to African Emergency care training.

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What do postgraduate examiners know about, and think of, standard setting in the College of Physicians of South Africa? S Schoeman,* V Burch, M M Nel *schoemanfhs@ufs.ac.za Background. Since its inception in 1954, the Colleges of Medicine of South Africa (CMSA) has used a fixed pass mark (cut-score) of 50% for all fellowship examinations in its 29 constituent colleges. From 2011, the College of Physicians (CoP) introduced standard setting (Cohen method) for components of their fellowship examinations. Despite an earlier workshop, it seemed that CoP examiners had limited knowledge of, and diverse opinions about, standard setting. Objective. To conduct a situational analysis of the current CoP examiners – to verify knowledge gaps and explore views, attitudes and perceptions towards standard setting. This research would guide the design of a focused workshop for CoP examiners about standard setting. Method. An anonymous online survey was sent to current (2010 - 2013) CoP examiners (n=51). Their knowledge of, and opinions about, standard setting were investigated. Results. Seventy five per cent of examiners completed the survey. Some examiners did not know that standard setting had been introduced; 21% for Part I MCQ exam and 45% for Part II Purpose Test. Altogether 21% were knowledgeable about, and 55% were familiar with, but not knowledgeable about, standard setting. A number of examiners (29%) had ‘no problem’ with using a fixed 50% pass mark, 32% were concerned about it and 39% rejected the practice. Most (63%) endorsed the changes made and 74% supported further implementation of standard setting in other CoP examinations. Conclusion. Although many CoP examiners endorsed standard setting, and some rejected the ongoing use of a fixed 50% pass mark, they had very limited knowledge about standard setting. CoP examiners, although broadly positive and supportive, need more information about, and a better understanding of, standard setting. Assessors in asessment C Tan* *tanplchristina@gmail.com Background. The assessment of clinical competence is one of the most important tasks facing medical teachers and is usually done at the end of their students’ clinical course to certify a level of achievement. It is also of importance because it is central to public accountability, as medical schools have a responsibility to ensure and demonstrate that a certain level of competency has been achieved in their graduating doctor. Much has been described about the tools for assessment, and who requires assessment, but focus should also be applied to the assessors, and how they are trained to assess. Observations made during actual Purpose Structured Clinical Examinations (OSCEs) in the final-year exit examinations in the Faculty of Medicine, University of Malaya in Kuala Lumpur, Malaysia, noted assessors engaging in inappropriate behaviours, such as prompting, indicating to the candidate how they had performed in the station, and also teaching/ correcting the candidate. There were also apparent differences in the way assessors used the mark sheets their departments had developed.

Abstracts Objective. To evaluate training workshops which have focused on addressing issues of consistency in marking and assessor behaviour. Method. Training workshops for OSCE assessors were initiated, focusing on assessor consistency in marking the checklists and assessor behaviour. Assessors who had undergone training were followed up in subsequent OSCE examinations to observe if there was any improvement. Observers completed checklists on assessor behaviour during the OSCEs, and their comments were analysed qualitatively. Results. Trained assessors were on the whole consistent in their behaviour, with minimal or no prompting as compared to untrained assessors. Conclusion. Training does help assessors become more consistent in their behaviour in OSCEs. Improving the reliability in OSCE assessors may contribute to more accurate assessment of the clinical competence of medical graduates. Second-year dental students’ perceptions about a joint medical curriculum L Bronkhorst, T C Postma* *corne.postma@up.ac.za Background. A recent study from Australia showed that dental students participating in a joint medical curriculum were being marginalised, which may contribute to unfavourable educational outcomes. Objective. Given the phenomenon of marginalisation in a joint medical curriculum elsewhere in the world, this study investigates whether there are perceptions among second-year dental students at the University of Pretoria, South Africa, that they are being marginalised in the joint medical curriculum they are participating in. Method. Quantitative and qualitative analyses were performed based on anonymous information obtained from 2011 and 2012 second-year dental students’ individual written reflection with regard to their first two years of study. The reflection was open to any comment the student wished to share and specific topics such as marginalisation were not mentioned as part of the instruction. Results. A total of 98 students consented to the use of their comments in the study. Although there was a fair amount of positive comments about the joint curriculum, 54% of the second-year dental students were of the opinion that the joint curriculum included too much irrelevant information, which contributed little to their skills as future dentists. Furthermore, 43% noted that dental students felt excluded during lectures and were disregarded by lecturers, and 42% felt that medical students were treated superiorly by lecturers. Conclusion. Universities utilising a joint medical curricula to train dental and medical students should be cognizant of the potential marginalisation of dental students. Two possible solutions may be to establish a dedicated programme to train dentists, which has the potential to improve the perceived relevance of the training, or to manage the joint curriculum to ensure that marginalisation is eliminated. Preparedness of graduates in occupational therapy for clinical practice: Perceptions of students and supervisors in a KwaZulu-Natal case study D Naidoo,* J van Wyk, R Joubert *naidoodes@ukzn.ac.za Background. Investigating the effect of curricular interventions and fieldwork placement on the competence and confidence of occupational therapists to

practise is an emerging field in South African occupational therapy research. It has become essential in educational research, as new graduates are often required to work autonomously during their community service. Objective. This study explored the perceptions of the final-year University of KwaZulu-Natal occupational therapy students and their clinical supervisors regarding their undergraduate education and preparedness for independent clinical practice. Method. Seventeen final-year students and their clinical supervisors (n=24) participated in focus groups and semi-structured interviews. Document analysis was conducted to compare the practice for training and assessment at the local institution with the stipulated guidelines from the Guideline of the World Federation for Medical Education and the national accrediting body, i.e. the Health Professions Council of South Africa. Results. Most final-year students and their supervisors indicated that students were only partially prepared and lacked confidence for clinical practice. Their confidence was better in areas of occupational therapy training that they enjoyed and experienced in a positive light during fieldwork placements. Curriculum review was identified as a priority. Conclusion. Both the clinical supervisors and the students felt that students would cope as new graduates after training in basic clinical practice. However, aspects of the curriculum could be improved to ensure that newly trained clinicians are more confident about their practice and better equipped to deliver an occupational therapy service specifically for the needs of the diverse African healthcare populations and settings. The home visit: Still a feasible teaching tool for medical students? A pilot study for curriculum revision D Michaels,* S Reid *des.michaels@uct.ac.za Background. For experienced family physicians the home visit can often re-connect them with the reasons why they practise medicine, while for students it is the ideal environment to counteract the effects of the ‘hidden curriculum’ in medical education. We conducted a pilot study to determine the logistic and pedagogic implications of home and clinic visits by medical students at the University of Cape Town. Objective. To identify potential obstacles, pedagogic strengths and logistic implications of home visits and patient accompaniment to clinic visits for its proposed inclusion in the curriculum. Method. 2nd- and 4th-year medical students were invited to participate in the patient follow-up pilot study which was conducted between May and August 2012. Quantitative and qualitative data analyses were conducted. Results. Thirteen (18%) 2nd-year and 4% (n=5) of 4th-year students completed the study. Student-initiated patient recruitment proved challenging to the majority (57%, n=8). All found the activity worthwhile. Eighty-six per cent (n=12) responded that the learning purposes could not have been attained without the home visit. The clinic visit accompaniment was not feasible, mainly due to the amount of time required. Ninety-three per cent (n=13) felt that a home visit experience should be included in the medical curriculum. Recommendations were made regarding patient recruitment and selection criteria, duration of follow-up, mentorship, support and assessment. Conclusion. The educational value of the home visit was confirmed; however, the clinical link must be made explicit and appropriate resources allocated to enhance the pedagogic value and feasibility of the activity.

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Abstracts Predictors of success for first-year students in health sciences: How useful are secondary school factors? U Naidoo,* P Flack, S Essack *naidoou@ukzn.ac.za Background. Universities in South Africa generally achieve low success rates, which translate to low throughput rates, especially in the first year of study. Student dropout in the School of Health Sciences (SHS) at UKZN has a two-fold consequence. It results in the loss of students and the loss of prospective healthcare professionals who are required to address the shortage of skilled healthcare workers in the country. Thus the need to determine factors that relate to success and throughput in the first year of study. Objective. This paper presents an aspect of a research project which explored factors that could be potential predictors of success in first-year students. The focus is on secondary schooling factors (area and type of schooling, matriculation point scores (APS) and matriculation subjects) in relation to first-year academic success in selected School of Health Science students over the period 2009 - 2011. Method. A retrospective design with a quantitative approach was used to collect data from 713 student records, from the 2009, 2010 and 2011 intakes. Quantitative data were analysed using descriptive and inferential statistic, while the Spearman rank correlation test and the Mann-Whitney test were used to determine differences among variables related to academic success. A p-value of ≤0.05 was considered statistically significant. Data were analysed and presented as annual composite results as well as stratified by disciplines as appropriate. Results. Overall the area of secondary schooling was not statistically significant as a variable that correlated with academic success. In contrast, the type of secondary schooling, matriculation points, and matriculation subjects investigated were statistically significant variables that correlated with academic success in the School of Health Sciences. At discipline level, physiology showed to have the most consistent correlations among variables, with a moderate correlation with matriculation subjects as well as the APS. Conclusion. The results of this study yielded evidence-based admissions criteria for students into the SHS at UKZN. Evaluation of a dental therapy curriculum using mixed methodology P Singh* *kissoonp@ukzn.ac.za Background. Dental therapists were introduced to the healthcare system to improve access to basic dental services for disadvantaged communities. However, studies have demonstrated that these professionals practise mainly in the private sector, serving a small minority of the population. This has perpetuated the lack of access for disadvantaged communities. Objective. To evaluate the dental therapy curriculum offered at a South African university to determine whether it produced appropriately trained graduates to meet the oral health needs of the population. Method. This study was conducted in four phases: context, input, product and process, which are analogous with Stufflebeam’s CIPP evaluation model. A combination of qualitative and quantitative research methods was used; with the Hicks curriculum design model serving as the theoretical framework,

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and pragmatism serving as its philosophical partner. Participants were selected by purposive and convenience sampling and included key external stakeholders, students and academics. Qualitative data were generated by interviews, focus group discussions and unobtrusive measures and analysed by thematic analysis. Quantitative surveys encompassed student module and competency evaluations. This information was analysed by descriptive analysis, which included frequency tables, graphs and percentages. Results. The results showed that the dental therapy curriculum followed the traditional subject-centred format, with a lack of integration between the basic, preclinical and clinical sciences. Training was based on a hospicentric, urban-based, curative training model, with little focus on primary healthcare. Conclusion. In order to develop professionals to meet the health care needs of a country, curricula should be evaluated iteratively, where the cycle of analysis, design and development, evaluation and revision are conducted as an ongoing exercise, using an appropriate evaluation model. Findings of this study gave rise to an extension of the Hicks model, which focuses on curriculum evaluation of health science programmes in developing countries. Assessment of the educational environment perceptions of senior medical students at the University of the Free State (UFS) S Schoeman,* C Ntsere, S Phate, L Khasoane, R Raphuthing *schoemanfhs@ufs.ac.za Background. The educational environment (EE) of a medical school plays a critical role in the learning of its students. It is the context or environment within which the students need to learn and master medicine. Factors that influence it include, inter alia, the learner, other learners, teachers and the physical environment (campus and hospitals). An accreditation report in 2010 by the HPCSA highlighted some concerns about our clinical training platform, and anecdotal challenges regarding the EE in the clinical departments were also surfacing from staff and senior medical students. This created the need to formally research the EE of the clinical phase of the School of Medicine (SoM) at the UFS, as perceived by the senior medical students (final 2 years – 4th and 5th year). Objective. To measure the senior students’ perceptions of the EE in the large clinical departments in the SoM. The effect of year group, gender, language, age and race were also investigated. Method. The internationally recognised and validated DREEM questionnaire was used and contextualised for each of the 5 departments included – Internal Medicine, General Surgery, Obstetrics and Gynaecology, Paediatrics, and Psychiatry. Only departments where 4th- and 5th-year students rotated in both years were included. Results. Overall response rate was 88%. Non-parametric tests and indicators were used to analyse the data since the majority of data weres not normally distributed. Overall median DREEM for the departments combined was 137/200. Paediatrics was consistently top rated and Obstetrics and Gynaecology consistently received the lowest ratings in all domains and subscale analyses. Gender had no influence and the other demographic elements had minor influences on the DREEM scores. Conclusion. The overall EE, as measured in the 5 large clinical departments, was more positive than negative, which is good news for the SoM. Although the subscale analysis largely revealed very positive results, some particular concerns were noted in one department.

Abstracts Does a structured dermatology surgical workshop make a difference in student learning? E Smuts,* A de Villiers, W Visser *estellesm@sun.ac.za Background. The formalised exposure of 4th-year MB ChB students to dermatology consists of a two-week clinical rotation in wards and outpatient clinics. In January 2011 a small surgical skills workshop was introduced in the first week of the rotation. Objective. To determine whether attending a small surgical skills workshop: (i) enhanced student confidence in performing the procedures; (ii) enhanced student competence in performing these procedures; (iii) taught increased student willingness to appropriate practice opportunities in the clinical setting. Method. Students’ surgical skills competency was assessed using an Purpose Structured Clinical Examination (OSCE). Two skills were assessed, namely punch and excisional biopsy. Qualitative and quantitative data were obtained by means of questionnaires. The first study group (n=24) completed the dermatology rotation in September 2010 before the introduction of the workshop. OSCE assessment took place in April 2011. A second study group (n=22) attended the workshop in September 2011. Assessment took place in March 2012. Time and student availability constraints caused a delay between attendance of the dermatology rotation (first and second study group) and workshop (second study group) and assessment of the students’ skill. Knowledge and skill decay were expected. Results. The students who attended the workshop demonstrated higher competence in the OSCE than the non-workshop students. Their confidence levels increased compared with the non-workshop group, and they were more willing to perform the procedures in the clinical setting. Conclusion. The introduction of the Small Surgical Skills workshop enhanced student learning of the particular skills. The researchers wish to suggest that a student’s request to perform more procedures under direct supervision in the clinic be strongly considered. Merit-based redistribution of students in anatomy dissection classes: Method revisited B M George,* S Nayak, S Mishra *bincyrajakumary@yahoo.com Background. At Melaka Manipal Medical College (Manipal Campus) we have adopted merit-based re-arrangement of students in the second term of their anatomy dissection classes in the first year of medical school. This method showed improvement in the individual scores in the subsequent examinations of the second term. Objective. The above distribution caused uneasiness, especially to the students who scored least marks in the first term. Some among them complained of being depressed after the re-distribution. The purpose of our intervention was to reduce the stress and anxiety, but achieve the same or better improvement in the exam scores. Method. The students were redistributed depending on the aggregate of marks of the two exams in the first term, but the groups were not assigned their meritorious ranks. Hence, the students were not told to which meritorious group they belonged, whereas the teachers were. This helped the teachers to teach to the groups accordingly.

Results. The students who scored less were not depressed as their scores were unrevealed to them and to their peers. Around 66% of students felt this method of redistribution is satisfactory. Conclusion. Student redistribution with unrevealed ranking almost erased the earlier uneasiness. Most of them were happy and felt that the course was delivered to them at their intellectual level. Comparison of effects of paragraph reading and mind mapping on shortterm memory P G R Kumari,* M C Naing, L A Yan, G C Ling, J R Antony, V Raj *grkumari@yahoo.com Background. The Mind Map is an expression of radiant thinking. Mind maps can be used as self-learning methods that facilitate understanding of difficult concepts. Objective. An attempt was made to compare the effectiveness of mind mapping and paragraph reading on visual short-term memory (VSTM) and to find out the most effective way of studying. Method. The study was done among the students of Melaka Manipal Medical College (MMMC) so as to enable their study performance and to aid in the effectiveness of teaching of the faculty. Students of MBBS phase 1 stage 1 (154 students) and phase 1 stage 2 (132 students) belonging to batches 28, 29 and 30 with a total of 286 students of MMMC were included in this study. The effectiveness of both the presentations on VSTM was evaluated by a set of questionnaire. Results. The results from both the groups of students were compiled and compared. These were analysed statistically by the chi-squared test. The number of correct answers of students exposed to paragraph format had a median of scoring of 5 - 10 questions correct, while the students who answered the questionnaire after exposure to mind map presentation had a higher median distribution of correct answers as 8 -13. Students would be able to recall more information from the mind maps rather than reading from the paragraph. The majority of the students in our study preferred mind maps to aid their learning process. Conclusion. Mind mapping has a greater impact on VSTM compared with that of paragraph method tool of learning in our study. Evolving a training programme for PBL tutors at Melaka Manipal Medical College (MMMC) for enhancing their facilitation skills: Students and faculty perceptions A Kukkamalla,* K L Shobha, A M Ciraj, J S D’Souza *anandkukkamalla@gmail.com Background. Problem-based learning (PBL) has been an integral part of our curriculum. PBL fosters students’ independent learning while tutors act as facilitators. New faculty members are naive to the PBL process, are not trained in facilitating it and yet are expected to facilitate the PBL sessions. Therefore a structured PBL orientation and facilitation skills module was designed. Objective. To create awareness of the PBL process and to design a training module for PBL tutors to enhance their facilitation skills and assess its effectiveness. Method. MBBS students (years 1 and 2) and faculty were included. After PBL orientation, pre- and post-test questionnaires (Likert’s scale with 20 items) were administered. PBL tutors later facilitated a PBL session. A pre-

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Abstracts intervention questionnaire (Likert’s scale with 20 items) on facilitation skills was administered. A one-day activity-based training programme on PBL facilitation skills was conducted for faculty. The same PBL tutors facilitated the next PBL sessions. Post-intervention questionnaires (Likert’s scale with 20 items) were administered. Results. There was a statistical significant difference in the median score for all 4 domains, i.e.: What is PBL?, PBL dynamics, individual roles, general attributes among students and domains 1 and 2 among faculty for PBL orientation. For facilitation skills, year 2 students showed a significant difference in all the 5 domains, i.e. being student-centred (facilitation skills), managing group dynamics, creating a motivating environment, using questions effectively, providing constructive feedback, and evaluation. Domain 1 was found to be statistically significant for year 1 students. Qualitative analysis of data of the training programme on facilitation skills also yielded significant results. Conclusion. PBL orientation and the training programme that was designed were found to be effective. Second-year students perceived that the facilitation skills of the tutors were enhanced when compared with the batch of 1st-year students. However, constant review, repeated orientation, implementation of the programme and assessment of skills are imperative. Standard setting in purpose-structured clinical examination (OSCE) in an undergraduate medical school: Will it improve the outcome? K L Shobha,* K M U Anand, M Manipal *shobhamicro@yahoo.com Background. Standard is a conceptual boundary on the true-score scale between acceptable and non-acceptable performance. The outcome of assessment is determined by the standard setting method. Objective. Since we did not have a valid and reliable OSCE stations and assessment system, stations were to be set and the standard setting method to be implemented, and outcome was assessed. The purposes were to: (i) develop reliable and valid OSCE assessment stations in clinical skills related to microbiology; (ii) analyse the scores obtained in OSCE using modified Angoff ’s method and a holistic method; (iii) collect the feedback from the students and faculty regarding the OSCE. Method. Four OSCE stations were developed, and checklists prepared after peer validation. The microbiology faculty and students were orientated regarding conduct and assessment of the OSCE. The modified Angoff ’’s method and holistic method were used for standard setting. Feedback on faculty and students’ perceptions regarding the OSCE was collected. Data were analysed using Prism software and SPSS 16. Results. Cronbach’s alpha was 0.901 for the reliability and validity of OSCE stations. The p-value was not significant for inter-rater reliability (Student t-test). Altogether 24.5% of students had failed in the modified Angoff ’s method when compared with the holistic method, which had only 14.25% failures. Regarding faculty perception, 90.90% of faculty felt that the OSCE was comprehensive, valid and reliable, while 77% of students felt the purpose of the skills was clearly defined. Eighty-nine per cent of students felt that the OSCE was stressful. Conclusion. Modified Angoff ’s method of standard setting was found to be more reliable and had good inter- rater reliability than did the holistic method. Periodic feedback helps for better conduct of the OSCE.

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Compilation of a WITS-CHSE database: Work in progress S Khan,* D Prozesky *sayedabanoo.khan@wits.ac.za Background. There is currently a large database of multiple choice questions (MCQs) in the WITS-CHSE resource base. Unfortunately clinical examiners are reluctant to use the database in its current format because of the system of classification of questions. Objective. The project aimed to address the problem by reclassifying the questions using a clinically orientated model. Method. A new classification model was compiled and adapted for the first phase of this project. MCQs for the MB BCh III and IV years of study were classified accordingly, spanning a duration of four years. In the original classification items were classified according to System, Discipline, Process, Transition, Taxonomy and Type, whereas the WITS-CHSE classification system uses the following categories: Discipline (29 categories), Clinical Process (12 categories), Pathological Process (19 categories), Transition, Taxonomy, Type and Statistics. Results. All MCQs were classified within the parameters of the original system as well as the WITS-CHSE system. It was found that there is no alignment between the original and WITS-CHSE databases. It is envisaged that the WITS-CHSE system will provide a user-friendly means for potential examiners to identify questions for examination papers. Since this is still work in progress, a more sophisticated method could be devised in the future using a computer-based software package. Conclusion. The WITS-CHSE database needs to be expanded to include MCQs for the clinical years and its use needs to be monitored. A database of MCQs adapted for the local context is necessary if it is to be useful effectively. Building together: Inter-faculty collaboration to create innovative learning opportunities and platforms for all involved students R Jansen,* J Hugo, M van Rooyen, A Reinbrech-Schütte *riaan.jansen@up.ac.za Background. The Department of Construction Economics (CE) in collaboration with the Department Health Sciences (HS) provided the opportunity for their students to apply their theoretical knowledge by means of real-life community projects. The purpose of the programme is to provide 80 healthcare centres which will enable students to spend their community work on career-orientated projects. This is done within the sites where re-engineering of PHC is done and ward-based outreach teams (WBOTs) are established in collaboration with the Department of Health. Objective. The programme integrates with the learning outcomes of CE and HS subjects, while also fulfilling the community’s needs and exposing CE and HS students to the latest innovative system; CE students are exposed to the planning, the manufacturing and the erection of the building system, while HS students will be the first to experience the benefits thereof. Method. An action research project was initiated, where CE and HS students were selected to participate. The action research include exposing students to concepts of planning, negotiation, networking, manufacturing, and construction in line with subject learning outcomes. Results. The year 2011 was spent in planning the best innovative system. Continuous assessment in these subjects showed marked improvements in the students’ conceptualisation, marks and overall involvement.

Abstracts Conclusion. Enriching the educational experience through the application of this service-learning model and exposing students to other students, the community and industry. HIV exposure incidents: An audit of reported incidents during 2012 to inform the development of a standardised protocol M van Rooyen,* T Rossouw, K Richter *marietjie.vanrooyen@up.ac.za Background. Medical students of the University of Pretoria are exposed to patients presenting with HIV- and AIDS-related illnesses as well as hepatits B and C on a daily basis. Although there is a protocol for dealing with such incidents it seems that there is room for improvement. The Department of Family Medicine was tasked to set up a protocol and take charge of the care of students presenting with an exposure incident. Objective. Evaluation of the management of exposure injuries. Method. An audit was done on reported exposure incidents in 2012. The results from the audit were triangulated with an anonymous questionnaire administered to all medical students, and compared with data from previous years. Results. • 125 exposure injuries reported. • 66.4% related to percutaneous injuries, • Most incidents happened in the casualty department and labour ward during or after venesection. • Most of the mucocutaneous exposures were related to either suturing or putting up a drip. • In most cases (91/125) the patient’s hepatitis status was unknown. • 29% (36/125) of incidents had a confirmed HIV-positive source. • A wide variety of PEP regimens were used. • Less than 1% of students followed up after the initial visit. Data from the questionnaire still need to be analysed. Conclusion. The exposure protocol needs to be revised and amended regularly. Innovative ways are discussed to deal with irresponsible practices in work-based situations, low follow-up rates, PEP regimens that are less than favourable and the unknown HBV and HCV status of patients. The knowledge and perceptions of pharmacists about the commonly sold herbal mixtures that are used as African traditional medicines in community pharmacies in Tshwane Townships, Gauteng M E Mothibe,* D Mpe, T Malesa, S Dipula, B Hlongwane, J Nabyoma *mamza.mothibe@ul.ac.za Background. Traditional medicines (TMs) continue to play a significant role in the treatment and management of diseases in the developing world. Commercialisation and marketing have popularised the herbal mixtures. They are available ready for use from pharmacies, muti-markets and other outlets. The many herbal mixtures sold over the counter in pharmacies have not been tested for efficacy and safety. As such, although they are readily available and used, their effectiveness remain unproven and their safety and toxicity profiles remain unknown. Objective. To determine the knowledge and perceptions of pharmacists about the commonly sold herbal medicines used as African TMs (ATMs) in Tshwane township pharmacies. Method. The study population for this study was the qualified and registered pharmacists working in community pharmacies in Tshwane

townships. Both qualitative and quantitative data were collected by means of self-administered questionnaires. Results. Most of the participants were aware of the use of ATMs and the recognition of ATMs by the National Department of Health. The majority believed that ATMs were used owing to their affordability and that the users trusted the medicines as they were considered to be natural products. They perceived it was appropriate for them to dispense ATMs, yet only 50% of them took safety aspects into consideration during dispensing. Although 83% of the participants had no formal teaching or training about TMs, the majority knew that the medicines are derived from plants. They knew the indications, routes of administration and storage conditions of most of the 10 commonly sold medicines, but not their safety aspects or interactions. Conclusion. The pharmacists perceived that although the safety aspects of the medicines are unknown, some ATMs are effective and trusted; hence it is appropriate that pharmacists dispense them. There are some knowledge gaps that exist due to unavailability of information about the medicines and their uses. To include aspects of ATMs in the pharmacy curriculum, as well as to regulate and standardise the TMs and their information. Prevalence of myopia among students: A cross-sectional study in a South Indian Medical College S R Kamath,* S D Jessica *surekharkamath@yahoo.com Background. Myopia is not only inherited but also caused by excessive reading and other close-up work. Generally, myopia first begins in schoolage children, since the eye continues to grow during childhood until about the age of 20. Objective. The purpose of the present study was to establish the various genetic and environmental factors contributing to the occurrence of myopia among students. Method. The prevalence of myopia among first-year medical students (N=115) of MMMC Manipal India was assessed using a questionnaire. These Malaysian medical students belonged to different ethnic groups, e.g. Chinese, Malaysian and Indian. Results. Our survey showed that females had a higher prevalence of myopia when compared with males of the same age group. A higher percentage of Chinese medical students were found to have myopia than other Malaysian races. The survey of myopia indicated the prevalence of myopia among several of our medical students. It also showed the different hereditary and environmental factors which could have led to the development of myopia in these students. Since our students work on computers and read often there is every chance of a non-myopic student developing myopia. Conclusion. Although there was an association with the level of education, gender, ethnicity and origin with the prevalence of myopia, its occurrence may be reduced by suitable awareness programmes and proper knowledge on development of myopia by environmental factors. Awareness about the side-effects of tattoos among medical undergraduate students of Melaka Manipal Medical College (Manipal Campus), India N Nagalakshmi,* A A Aaron, D Miller, T W Yi, D Kumaran *nagubrp@gmail.com Background. While tattoos have been around for centuries, in recent years they have become increasingly popular, especially among teenagers.

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Abstracts However, as the popularity grows, so do the concerns over the safety and risks of tattoos. Little attention has been directed to the potential latent health effects of tattoos. Some of the risks that come with a tattoo are infection at the site of the tattoo, an allergic reaction to the tattoo dye, the spread of disease such as HIV and hepatitis C, granulomas and keloid formation. Objective. To investigate the awareness about the side-effects of tattoos among medical undergraduate students of Melaka Manipal Medical College (Manipal Campus), India. Method. A total of 200 students from Melaka Manipal Medical College (Manipal Campus) participated in this study. Awareness about side-effects of tattoos was analysed using pre-set questionnaires. Results. Of 200 students who responded to questionnaires, we found 11% have a tattoo, 38% are considering getting a tattoo and 70% do not have a tattoo. Only 17% of the students were aware of needle sterilisation. Altogether 70.5% of students were aware of the hazards of tattoos and diseases transmitted by needle-stick tattoos. From the data obtained, we can come to a firm conclusion that the hypothesis is accepted that 62% of respondents do not have adequate awareness about the side-effects of tattoos. Conclusion. Different cultures have their own perception regarding tattoos. It’s important to create awareness about side-effects of tattoos among teenagers to prevent transmission of infectious diseases such as human immune deficiency virus, hepatitis B and C virus. International classification of functioning, disability and health (ICF): A framework for transformative interprofessional education S Snyman,* M Clarke, K von Pressentin *ssnyman@sun.ac.za Background. To promote health equity, a focus is needed on providing patient-centred and community-based care. This is a challenge for health professions educationalists as they advocate for instructional and institutional reform, which includes interprofessional education (IPE). As a solution the WHO recommends using the ICF framework. Since 2010 Stellenbosch University’s IPE strategy has promoted the ICF. Clinical training of undergraduate health professions students includes rural placements where students use the ICF framework in managing and presenting patients, and are assessed by interprofessional teams of local healthcare professionals. Objective. To establish how applying the ICF framework as IPE strategy contributed to (i) instructional reform; (ii) institutional reform; (iii) interprofessional practice; and (iv) functioning of health systems. Method. Associative group analysis – an unstructured method of qualitative research used to reconstruct people’s subjective images from the spontaneous distributions of their free associations – was used to conduct this study. Questionnaires were administered to 70 participants: 37 fourth-year students, 18 facilitators of learning, and 15 patients. Free word associations were used to reconstruct the internal world and subjective meanings expressed by more direct methods. Results. Students indicated that they adopted a patient-centred approach which improved patient outcomes and satisfaction. This was confirmed by health professionals, who felt they were indirectly challenged to practise patient-centred, interprofessional care as a result of them assessing students applying the ICF. They reported improved interprofessional collaboration, interprofessional practice and job satisfaction as they started applying the

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ICF in clinical practice. Patients appreciated the improved quality of care. Conclusion. The assessment of student presentations using the ICF framework drives interprofessional practice among healthcare students and professionals, facilitates the bio-psycho-social-spiritual approach to patientcentred care and results in improved patient outcomes and strengthened health systems. Journey from transformative education to transformational leadership L S McNamee* *mcnameel@ukzn.ac.za Background. Transformative education is characterised by a change of ‘habits of the mind and heart’. Medical education has been recognised, like other educations and apprenticeships into professions, as a self-altering course of identity construction (and reconstruction). Transformational leadership implies that the change within has influenced others and brought about change without. All medical practitioners are arguably leaders in society due to the status and position afforded them by virtue of their qualification. Yet the field has generally lagged behind in the adoption of contemporary transformational leadership models which are more likely to effect meaningful change in healthcare systems. Objective. The study aimed at better understanding the development of a professional identity as medical students become doctors. Various factors that influence aspirations, motivations and trajectories of newly qualified doctors (NQDs) are being explored in an on-going study. Method. Six graduates of a PBL curriculum participated in a narrative study of medical internship experiences. Qualitative data in the form of written reflections 3 years post-graduation were analysed using sociolinguistic methods. The same participants were followed up with one-on-one, in-depth interviews 6 years post-graduation. Interpretative evaluation enabled insight into their journeys as professionals while reflecting back on internship experiences from a more mature perspective. Results. A synopsis of how graduates reached their current professional positions 6 years post-graduation showed that in addition to knowledge, skills and values participants’ experiences relating to ‘life and fate’ have an unexpectedly profound bearing on career choices. Relationships to others and to institutions, both pre- and post-graduation, were found to be a central theme in the trajectories of NQDs. In addition, national policies governing post-internship placement of practitioners in community service were a further compounding factor highlighted by participants’ narratives. Conclusion. Beyond transformative undergraduate medical education lies a liminal space fraught with complexity, unpredictability and uncertainty. NQDs should be equipped to deal with contextual and cultural aspects of medical practice in order to develop as transformational leaders. Enhancement of postgraduate skills through an educational programme B Kotze* *bekotze@cut.ac.za Background. All healthcare professionals must be registered with the Health Professions Council of South Africa (HPCSA). The council requires healthcare professionals to register as a professional with the required education and training, to conduct themselves in an ethical manner, to continuously develop professional skills (CPD) and to comply to healthcare standards as set out by the Health Professions Act No. 56.

Abstracts Objective. The study, as one of its possible outcomes, evaluated the effectiveness of utilising an educational programme (offered as a CPD event) to enhance a specific professional skill (neonatal chest image quality) of postgraduates (radiographers). Method. An essential skill required from all radiographers in clinical practice was evaluated in three institutions. The skill was evaluated by means of an international standardised checklist. Areas in need of enhancement, found in the skill, were identified and addressed through an educational programme, offered as a CPD event. The programme consisted of various contact sessions, practical sessions and poster presentations. The effectiveness of the programme was established by re-evaluation of the specific skill of the radiographers found in three institutions, both private and governmental. Results. The quantitative and qualitative results indicate that most participants (radiographers) found the educational programme both informative and enlightening. However, quantitative results from the re-evaluation of the skill in clinical practice showed a low percentage of enhancement. This indicates that even though CPD events strive to improve skills and develop professionals, it is not guaranteed to be successful. Conclusion. CPD skill development plans through educational programmes should be thoroughly revisited and re-evaluated to establish if it truly can enhance a professional’s skill. Collaborative learning as a transformative force for social inclusion V S Singaram* *singaram@ukzn.ac.za Background. Among the challenges faced in South African education is the need to transform its face, its function and its folk, drawing the three aspects away from the divisive apartheid past towards a more inclusive, affirming and enabling future. The thrust of transformation underscores the tension between eliminating the inequities of our past and remaining conscious of our people’s underlying diversity. Collaborative learning is ideally suited to helping students mediate and explore the tensions of transformation as well as the discomfort of diversity. Objective. To explore the use of collaborative learning as a transformative tool for social cohesion in higher education. Method. In this study, data from focus group interviews conducted among a stratified sample of second-year medical students and teachers of problembased learning (PBL) were analysed using Mezirow’s first phase of the process of transformation. This phase poses ‘a disorienting dilemma’ – a situation in which new information clashes with past beliefs, leading to self-examination, critical assessment of assumptions and a new perspective. Results. Four major transformational dilemmas are identified. We show what aspects of diversity are operating in our student population and suggest what may be done to maintain a constructive balance between the polarities. Conclusion. We argue that collaborative learning is an effective way of presenting these aspects to a diverse, heterogeneous student population for their reflection towards personal transformation. As highlighted by Mezirow (2003), transformative learning involves critical reflection on assumptions that may occur in group interactions. Our findings support the role of collaborative learning as a transformative force in higher education.

Situation analysis of the training of eye healthcare professionals in four African countries G du Plessis, D Prozesky* *detlef.prozesky@wits.ac.za Background. The Vision2020 global initiative aims to eliminate avoidable blindness in the world by 2020. One of its three core strategies is human resource development for eye care. Objective. The research aimed to assess the educational quality of training programmes for eye care professionals in Eritrea, Ethiopia, Kenya and Rwanda. Method. All but two of the recognised training programmes were identified and sampled. Following negotiations with national bodies and training institutions, on-site visits to each programme were carried out over a period of three months. Data collection instruments were developed for interviews with managers, teachers, students and graduates, and structured observation of the training environment and documentation. Results. Altogether 16 programmes were evaluated: four for ophthalmologists, four for optometrists and eight for mid-level workers. Considerable strides have been made in establishing training programmes, often with severe resource limitations. Most curricula revealed deficiencies due to not having been derived through a rigorous process of task analysis based on a prepared list of capabilities. The quality of teaching and assisting student learning varied: one-way lectures were commonly used, lesson plans were absent, and support material for knowledge and skills learning was significantly lacking. Skills teaching mostly followed a relatively unsystematic apprenticeship model. Assessment of learning was problematical in terms of validity, reliability and technical quality for cognitive and skills assessment. Explicit educational quality assurance systems were not found. In addition to these educational findings it became clear that training is significantly affected by wider systems issues such as cadre recognition, accreditation, and human and physical resources for training and in the workplace. Conclusion. There is a clear need for educational expertise in the programmes. Based on the findings of the evaluation, an educational package is being developed. Training programmes for health professionals may lack basic educational expertise. Peer assessment of quality in teaching and learning F Oosthuizen,* J Bodenstein, S Y Essack *oosthuizenf@ukzn.ac.za Background. Quality teaching is a central tenet to the retention and success of students in higher education, but teaching quality measures and indicators have not enjoyed debate and discourse within the higher education sector as much as research has. Quality measures such as pass rates, student and peer evaluations of teaching, moderator and external examiner reports, reports from student support personnel, feedback from experiential learning supervisors and institutional research on teaching and learning may be used to inform quality improvements in teaching and learning. Objective. To evaluate the use of peer evaluations of teaching to inform quality improvements in teaching and learning. Method. Peer evaluations were conducted using a team approach with the team consisting of an internal academic, an academic external to the

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Abstracts University and a healthcare professional in clinical practice. Peers were provided with comprehensive information on the module, including but not limited to content, assessments, notes, practical/experiential learning manuals/log books, past test and examination papers and performance trends prior to conducting evaluations. Each peer individually completed a peer evaluation questionnaire after all peers observed teaching practice as a team and submitted a team report. Results. Academic participants unanimously agreed that qualitative data from peers were best able to highlight strengths and weaknesses as well as assess standard of content at national professional/peer level and qualitative data provided the most useful data to inform changes in teaching practice. The qualitative data engendered and enhanced reflective practice and were of greatest use for teaching portfolios. Conclusion. Peer evaluation is a suitable tool/indicator/measure for quality teaching as it provides holistic feedback and engenders reflective practice, positively impacting on the quality of teaching. Prizes and surprises: Evaluation of the SAFRI fellowship programme D Manning,* J Bezuidenhout, J Frantz, V Burch, J van Wyk, J Blitz, S Friedman *dianne.manning@up.ac.za Background. The sub-Saharan Africa FAIMER Regional Institute (SAFRI) delivers a faculty development fellowship which is aimed at capacity building for educators of health professionals. A traditional approach aligned with Kirkpatrick’s four-level model has previously provided a useful framework for evaluating the fellowship. This model interrogates reaction/ experience, learning, behaviour change and results/impact. However, a recent paper by Haji et al. (2013) encourages us to rethink evaluation of education programmes by considering whether it worked, how, why and what else happened. Objective. To consider how a different approach can be used to rethink evaluation of the SAFRI fellowship. Method. A number of different evaluation tools are used, including daily surveys to collect data on reaction and learning, a retro-pre-post survey on perceptions of learning, assessment and evaluation of online distance learning, an online portfolio of professional development for documenting activities, leadership roles, and scholarly achievements. Fellows present education intervention projects and share personal and career successes. Results. The information gathered provides valuable feedback at all four Kirkpatrick levels, strongly indicating that the fellowship ‘works’. How and why it works emerges from the individual stories shared by fellows at the on-site sessions and on the dedicated listserve. Their accounts emphasise the important role played by the mentorship and support they receive as part of the community of learners which they have joined. Context-related surprises have included the spread of the programme to include fellows from beyond southern Africa, necessitating a name change of the institute, and the rapid appointment of a number of fellows to senior leadership positions. Conclusion. Evolving concepts of evaluation encourage a richer understanding of programme outcomes.

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Transforming the examination process of the Examination Council of Health Sciences of the University of Zambia School of Medicine C Marimo,* F M Goma *chikacle@gmail.com Background. The Examination Council of Health Sciences (ECoHS) oversees the examination process of affiliated health sciences programmes at colleges in Zambia. Examination malpractices have been a chronic problem despite the presence of control mechanisms and penalties including prosecution in court. The types and levels of examination malpractices were especially alarming in the December examinations of 2011. An instituted ad-hoc committee found that examination malpractices were rampant with intricate mechanisms of evading identification at the student, trainer levels and possibly the ECoHS centre itself. Notably, weaknesses were identified in the trainers’ preparation of the examination papers, security in the examination hall and trainers marking schedules. Objective. To address the examination malpractices of affiliated health sciences programmes at colleges in Zambia. Method. Prepare examination questions from the prescribed and recommended readings guided by the curricula of each affiliated programme to create a bank of questions in ECoHS. One person activates and prepares the examination paper using a specially designed software programme with features that include unique access codes, random selection of examination questions and weighting in terms of difficulty from mild, moderate to difficult. The printing and auto-packaging of the examination paper will be on camera with an inbuilt mechanism of tracking any spoiled papers that have to be signed for and destroyed on camera. The chief invigilator with newly trained personnel secures the examination venue and entrants as well as collecting all answer sheets including spoiled ones and notes for submission to ECoHS. Correction of answer sheets, compilation and submission of marks will be under supervision at a single venue. Results. SouthernSoft Technologies are developing the software programme and ECoHS holds the bank of questions. Conclusion. Security of the examination process has to be equal or better to types of examination malpractices in order to improve or maintain the integrity of the qualification. An assessment of the impact of academic development officers’ interventions in challenging modules in the College of Health Sciences at the University of KwaZulu-Natal B Mkhonto,* L Qulu, C Subiah, Z Ndlazi, P Mudaly, N Mchunu *mkhontob@ukzn.ac.za Background. The College of Health Sciences comprises four schools (School of Clinical Medicine, Health Sciences, Laboratory Medicine and Medical Sciences and School of Nursing and Public Health). Two core modules, anatomy and physiology, are common to all disciplines within the College. Over the years, these modules have proven to be challenging to many students. The poor performance in these modules has impacted negatively on student throughput within the College.

Abstracts Objective. In an effort to combat this poor performance challenge, the College implemented various forms of interventions including the appointment of academic development officers (ADOs). Students who have failed modules, were made aware of the academic development interventions available to them in order to improve their performance. However, students access the ADO services on a voluntary basis. Method. The performance of students who accessed the ADO programme was monitored throughout the semester. A retrospective data review was conducted with regard to mid- and year-end examination performance of repeat students. Results. Our findings have shown that students who accessed ADO intervention improved their academic performance in physiology and anatomy, in comparison to those who did not make use of the service. Conclusion. This finding underscores the importance of providing academic support to students through ADOs. Success v. failure: An evaluation of student success in the emergency medical care programme against the course selection criteria at Central University of Technology, Free State M van Eeden,* R G Campbell *mveeden@cut.ac.za Background. Selection of candidates for admission to the National Diploma: Emergency Medical Care programme (NDip: EMC) at the Central University of Technology (CUT) remains a challenging process. Admission criteria provide clear guidelines for school-leaving applicants, but grey areas exist with the selection of mature learners (â&#x2030;Ľ24 years of age) and those between leaving school and the mature category. The use of the Matric Score (M-score) with prerequisite subjects is standard practice. The General Scholastic Aptitude Test (GSAT), considered a valid tool measuring academic potential, is also used. Besides academic criteria for admission to the programme, physical fitness and environmental tolerance criteria need to be met. Objective. To explore a correlation between student success and academic admission criteria. Method. A retrospective analysis of selection results for admitted candidates to the NDip: EMC at CUT from 2004 to 2010 will be conducted together with an analysis of corresponding graduates from 2006 to 2012. Correlation between selection test results and graduate success of students will be identified. Results. The hypothesis is that there is a relationship between traditional selection criteria and successful achievement of the qualification. The cohort of students in the mature category who have demonstrated success without having met all the prerequisite admission criteria may point to other characteristics that can be used to predict success in the programme. Conclusion. The anticipated outcome of this study is to identify criteria that are predictors of success that can be used when selecting older students for the Emergency Medical Care programme at CUT. Student support: Developing a consultation framework A Bawoodien* *azizab@sun.ac.za Background. There is mounting pressure on medical schools in South Africa to increase the intake of health science students and ensure optimal

throughput of its recruits. Primary and high school education has undergone many changes over the last decade in the country, causing uncertainty about the preparedness of recruits for tertiary education. Additionally constraints in facilities to deal with the numbers and the shrinking base of health science educators call for greater support of the student who may not be adapting. Formal or informal accessible student support structures exist at most institutions. At a 2012 SAAHE workshop it became apparent that a diversity of professionals were involved in student support, viz. lecturers, family physicians, physicians, psychologists, social workers, and educationists. Objective. To develop a standardised framework to interview students identified for support. Method. Reflect retrospectively on students presenting for student support. Identify literature to substantiate the reasons for utilisation of support. Develop consultation guidelines which can be generalised for use by student supporters. Results. Students entering health science institutions in South Africa are predominantly in the late adolescent stage of emotional development and top performers from an economically stratified range of schools. When they start underperforming they go through a spiral of psychological changes including feelings of embarrassment, social withdrawal and alienation to overindulgence and seeking of power positions in non-academic activities. It is also an age group where there is an increasing incidence of psychiatric morbidity and where they are not forthcoming with the reasons for underperformance. Many student supporters work in isolation, sometimes perceived as a threat to students and faculty. Conclusion. A standard approach to deal with the complexities that come in the guise of academic underperformance is necessary to implement remediation and exclude pathology. Studentsâ&#x20AC;&#x2122; experiences and perceptions of a community-based medical education programme at the University of KwaZulu-Natal K Naidoo,* M Muzigaba, P McNeill, M Naidoo, R Govender, C Rangiah, M Kendon, S Pillay, U G Lalloo *naidook7@ukzn.ac.za Background. In 2013 the University of KwaZulu-Natal introduced a community-based education programme for 4th-year medical students in Family Medicine. The programme involves provision of accommodation, transport, tutors and IT facilities by the UKZN Medical Education Partnership Initiative (MEPI) to enable groups of 30 - 40 students to conduct clinical rotations in urban and rural primary healthcare centres. Objective. A formative evaluation to investigate the studentsâ&#x20AC;&#x2122; experiences and perceived effectiveness of such a programme in achieving predetermined learning purposes. Method. All students who completed the rotation in the first 2 quarters of the 2013 programme were invited to complete a survey questionnaire to evaluate their perceptions and experiences of the programme. The main outcome measures were self-assessments of knowledge and skills pre- and post-introduction of the community-based education programme as well as an evaluation of the teaching methods. Results. Between January and May 2013, there were 89 students who underwent the rotation (half the class) and completed the evaluation. The overall satisfaction of the students with community-based placements was high (83%). More students felt that small group tutorials (88.9%) and bedside teaching (86.7%) were effective teaching methods compared with

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Abstracts lectures (70%) and an online platform – MOODLE (73%). Based on the mean difference (MD) of pre- and post- perception scores computed on a scale of 1 - 5, the most significant gain that students perceived was in their understanding of chronic illnesses (MD -1.27). The learning purpose of understanding patient context was also well met (MD -1.05). However, students’ perceived gain in patient communication only reflected a MD of -0.88. More than 80% of respondents indicated that the relationship with their supervisor and facility staff was positive and enhanced the learning experience. Conclusion. Training health professionals in the community is resourceintensive and requires innovative pedagogy in order to achieve the desired purposes. However, in this Family Medicine programme at UKZN, attaining specific learning purposes such as understanding patients’ context and chronic diseases has been demonstrated to be effective with communitybased education. Further evaluation of community placements and pedagogies required is needed to inform educators of how to best implement community-based education. Developing students’ isiXhosa and Afrikaans communication skills for the clinical consultation: A Stellenbosch University Faculty of Medicine and Health Sciences initiative M F Sikele,* P Lewis, M de Villiers *fezs@sun.ac.za Background. In a multilingual country comprising 11 official languages nationally and at least three in each of the nine provinces, communication (language and cultural) barriers experienced between healthcare professionals and non-language concordant patients are well documented and perceived as a major challenge to quality healthcare in South Africa. Since 2011, Stellenbosch University Faculty of Medicine and Health Sciences (SUFMHS) embarked on a distinctive roll-out initiative to integrate the teaching and learning of isiXhosa and Afrikaans communication skills into the clinical consultation. This initiative is being rolled out in all 5 undergraduate programmes at SUFMHS. Objective. This presentation provides an overview of past trends that have led to the implementation of current as well as future anticipated innovations designed to optimise SUFMHS medical and allied trained health professions students’ isiXhosa and Afrikaans communication skills for the clinical consultation. Method. Various innovations, ranging from the implementation of communicative-based teaching and learning classroom practices and assessment procedures accompanied by the introduction of two novel technologically based platforms will be reflected upon and discussed as ways to (i) support and reinforce students’ isiXhosa and Afrikaans communication skills; and to (ii) ultimately optimise students’ isiXhosa and Afrikaans communicative competency for the clinical consultation. Results. The importance of sharing on-going teaching and learning innovations among peers interested in implementing similar related initiatives is expressed and encouraged. To demonstrate the contribution provided by such integral innovations, a video will be presented and briefly discussed to illustrate students’ acquired isiXhosa communicative competency while engaging with an isiXhosa-speaking simulated patient during a clinical consultation. Conclusion. South Africa is faced with huge communication barrier challenges in the healthcare sector. Faculties of Medicine and Health

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Sciences are encouraged to be more involved with innovative initiatives that will become integral to the complete training of a health professional in a multilingual society. Trends in Xhosa language teaching and learning at faculties of medicine and health sciences: Findings and new initiatives M du Plessis,* M de Villiers *mads@sun.ac.za Background. Communication problems between healthcare workers and patients are perceived as a major barrier to quality healthcare. There are generally very few effective language programmes that equip student professionals with communicative skills in the context of their profession. Therefore, the education system produces healthcare professionals who are communicatively incompetent in the languages of their patients. In 2011, Stellenbosch University Faculty of Medicine and Health Sciences (SUFMHS) embarked on a new initiative. This initiative includes the implementation of communicative-based Xhosa courses in all undergraduate programmes with the focus on learning how to communicate in a clinical context. Objective. This is a comparative study conducted on Speech-Language and Hearing Therapy I and II students to determine their perceptions about their Xhosa proficiency in the respective Xhosa courses they have received. Method. Two groups of students are participating in this particular study, i.e. Speech-Language and Hearing Therapy I and II students. Each group comprises approximately 30 students. The students participating in this study are not first-language speakers of Xhosa and furthermore they have not received the same Xhosa course. The study made use of a survey, consisting of open and closed questions, as well as open-ended questions, which determined the perceptions and attitudes of students towards the teaching and learning trends of the respective Xhosa courses they attended. A second component comprises students having to express their feelings by the use of drawings on the Xhosa course they have received. Results. The data will be captured through the specific questionnaire and then be analysed by comparing the responses obtained. The information of the two respective groups will be compared. The results will be finalised in May 2013. Conclusion. Faculties of medicine and health sciences are encouraged to expose students to communicative-based classroom settings that nurture meaningful and interactive clinical communication skills in order for them to become an integral part of the community. Family medicine training as a specialty: The University of Limpopo (UL) experience (the new family medicine specialisation training will be discussed with the lessons from this new course) I Govender, J Tumbo* *tumbo@lantic.net Background. The district health system was adapted as the vehicle for healthcare delivery in South Africa in 1994. Family medicine and primary health care weres identified as a key pillar of the district health system. Therefore, the 8 academic departments of family medicine aligned their undergraduate and postgraduate training to this national priority. Until 2007, family medicine Masters programmes were part-time vocational courses at all universities. In 2008, UL developed a new curriculum based on the outcomes set by the Family Medicine Education Consortium (FaMEC)

Abstracts and a full-time residency programme. Provincial departments of health developed training platforms for the universities. Within this platform district training complexes were developed. There were joint appointment of trainers between provincial departments of health and universities. Results and Discussion. The context of training was identified as the district health services. Training complexes were accredited by the HPCSA in 3 provinces (Gauteng, Limpopo, North West). UL prepared for this new course by training 17 family physicians from University of Limpopo to become facilitators in the new programme which was conducted with extensive learning from the Belgian family medicine training programme. The HPCSA accredited 60 Family Medicine registrar training positions for the University of Limpopo. The curriculum is structured into 36 Modules (17 in year 1, 10 in year 2, and 11 in year 3), with 3 training sessions at the university and 3 at a provincial training site per year for 2 days. There was constant supervision by a Family Physician at the training site and weekly seminars by all registrars at the site. Challenges of running the training include a limited number of funded registrar posts by the provincial health authorities (employer), shortage of supervisors to meet the needs, change management in implementing the intensive on-site supervision, limited interest and understanding of family medicine specialisation among generalists Lessons learnt: • need for proper planning and marketing of family medicine specialty. • crucial stakeholder buy-in, particularly from the Department of Health that employs registrars and specialists. • national consensus of medical schools on standardisation of training and outcomes • need to customise the curriculum to address local country needs and improve on retention of specialists Conclusion. The University of Limpopo has made significant strides in the implementation of training of family medicine as a speciality in the district health context. Collaboration between academic institutions and provincial health authorities is crucial in the success of training of family physicians. Curriculum issues affecting rural-origin health science students across three South African medical schools P N Diab,* P S Flack, H Mabuza *diabp@ukzn.ac.za Background. Recruitment and retention of staff to rural health facilities is a global challenge. Past research suggests that students from rural backgrounds are more likely to go into rural practice. However, these students face a number of challenges. Overcoming those challenges is key to ensuring their retention and success through the academic programme and to increase the likelihood of their subsequent decision to practise in rural communities. Objective. This paper examines to what extent the curriculum influences such decisions and interrogates students’ opinions as to their exposure to rural health and the challenges that rural students face during their undergraduate education that may affect their final decision to practise in a rural area. Method. A study conducted at three South African medical schools was conducted using a self-administered questionnaire. First- and final-year

students from all health science disciplines were sampled. Data were entered into Epidata and analysed using SPSS (version 19). Chi-square tests were utilised to determine statistical significance of the quantitative data while qualitative data were analysed thematically. Results. The majority of students (59.9%) knew of modules exposing them to rural health and believed that this was sufficient. Students felt that such modules should be introduced early and sustained throughout the curriculum and that such exposure was important in terms of preparing them for future practice. The biggest challenges for rural students were the language of teaching, technological and financial issues. Academic course content, personal challenges or adaptation to urban life were no more challenging for rural than urban students. Conclusion. Students reflected past research that rural health should be introduced early and sustained throughout the curriculum. Language support and technological skills training may be required to assist rural students. Seeking ways to alleviate or reduce these stresses may well influence future recruitment of rural students to rural practice. Review of final-year medical students’ rural attachment at district hospitals in KZN P N Diab,* P D McNeill, A Ross *diabp@ukzn.ac.za Background. Many medical schools utilise community-based training facilities to expose students to undifferentiated patients presenting to primary healthcare facilities within the community. The programme at UKZN has been in existence for some time but no formal evaluation of the programme has yet taken place. Objective. In preparation for a new 6-week attachment commencing in 2015, this review aimed to investigate the programme from the viewpoint of the site supervisors and students. Method. An exploratory research design was used. Purposive sampling of supervisors involved with the training at the time of the review was undertaken and in-depth interviews were conducted using a semistructured interview guide. Data were collected from students by means of a self-administered questionnaire at the end of the block. Interviews were transcribed and a thematic analysis of the data is presented in this review. Quantitative data were analysed using SPSS (version 19). Ethical approval was granted by the UKZN Humanities and Social Science Ethics committee (HSS/1347/010). Results. Communication issues, including frequent liaison between academic institutions and hospitals, preparation of supervisors and frequent visits from university staff were highlighted to be of importance. Assisting with the structuring of a programme and providing daily rosters and clear lines of delegation of students were also essential. Preparation of students was seen to be an essential factor in the overall success of the programme. Support structures including accommodation, technical support and recreational opportunities were seen to be important factors to address. Conclusion. Regular review of such programmes is vital in order to ensure its sustainability and gain the best possible outcome for students, supervisors and institutions to which they belong. The activities performed by the students should be under-pinned by a theoretical perspective and focus not just on skills acquisition but on the broader experience of life and work in a rural district hospital.

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Abstracts Career and practice intentions of health science students across three South African medical schools C Naidu,* J Irlam, P Diab *claudia.naidu@uct.ac.za Background. The distribution and accessibility of healthcare professionals as well as the quality of healthcare service are significantly affected by the career choices of health science graduates. Objective. This study aimed to provide insight into the future career plans of health science students across three South African medical schools, and to identify some of the factors which most strongly affect these preferences. Method. A self-administered survey was conducted of first- and finalyear health science students at the University of Cape Town, University of KwaZulu-Natal and University of Limpopo. All data were entered into Epidata and exported for analysis using SPSS. Results. The overall response rate was 52% (n=1 676). Just under half of all respondents (49%, n=771) intend to work after completing their undergraduate studies, 43% (n=333) of whom would like to work in a rural area. The most popular choices of institutions were district hospitals, private hospitals and tertiary hospitals. Forty-one per cent (n=654) of respondents intend to further their studies, and for medical students (n=396), the most popular specialties included surgery, paediatrics, cardiology, neurology, obstetrics and gynaecology, and internal medicine. Just under half of all respondents intend to work in another country (47%; n=748), primarily motivated by career development, financial reasons and wanting to learn about a new culture. Conclusion. The findings demonstrate that students are influenced by a multitude of factors in making their career choices and emphasise the need to design specific strategies to overcome the maldistribution of health professionals across sectors, geographical areas and specialities. Why medicine? A survey of medical students at the University of Botswana N L Badlangana* *nlambiwa@gmail.com Background. Botswana is a large country with a population of ±2 million. However, the number of doctors is very low. There is no direct entry into the School of Medicine (SOM) and students have to apply for admission. If we can identify early why students choose medicine we hope that they will not only stay in medicine, but will practise anywhere in the country for the benefit of its citizens. Objective. To determine the reasons why medical students at the University of Botswana SOM chose medicine as a career. Method. An online survey using Survey Monkey was developed using comments and suggestions from focus group discussions conducted separately with lecturers and students. The survey included questions on influences and reasons to study medicine, alternative career choices (if any), strengths of studying in Botswana, expectations for student achievement at the SOM and expectations on graduation. The 2nd-, 3rd- and 4th-year students were invited by e-mail to participate in the online survey. Results. Forty students responded (response rate = 50%). Altogether 74% (n=28) indicated their greatest influence for studying medicine

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was personal experience rather than parents and relatives (2.6% each), while 28.1% (n=9) indicated their choice of medicine was to have a stable job after graduation. When asked what they would have studied if not medicine, 41.7% (n=15) responded that they would have studied another health sciences field (e.g. dentistry, nursing, pharmacy, physiotherapy). On the choice to study medicine in Botswana, 80.6% (n=29) responded that the relevant conditions they might see when they start practising medicine was a strong factor, as they would be familiar with certain conditions that they would have encountered in the course of their studies. Conclusion. Students are interested in medicine. Their experiences play an important role in choosing medicine as a career. Challenges faced by rural-origin health science students across three South African medical schools: A focus on support P Flack,* V Singaram *flackp@ukzn.ac.za Background. There is vast body of literature that suggests those students most at risk for drop-out, or non-persistence, are students from disadvantaged backgrounds (Braunstein, Lesser, and Pescatrice, 2008), students whose language for learning is not their mother tongue and students who enter the tertiary education sector ill prepared academically owing to the existing disparities in the primary and secondary levels of education. Many of these students who enter the tertiary education sector ill prepared are from rural backgrounds. A student who feels alienated, alone and unsupported is at high risk for ‘non-persistence’ or drop-out (Quarterman, 2008). Therefore, in order to improve retention it is essential to ensure students feel supported, included and socially integrated at university. Objective. The focus of this paper is on the support required and accessed by students from rural backgrounds in particular. Method. This study was conducted at three South African universities. Health science students in their first and final years of study completed self-administered questionnaires. Students identified themselves as either of rural or urban origin in the questionnaires. Data were analysed according to those two categories. Data were entered into Epidata and analysed using SPSS (version 19). Chi-square tests were utilised to determine statistical significance of the quantitative data while qualitative data were analysed thematically. Results. Rural students report requiring support to overcome the following challenges: the language of teaching and learning, computer literacy and other technological issues, and financial constraints. Support is accessed from family and friends, and religious communities, in a similar way to urban students. However, peer mentors were considered less supportive unless they too shared a rural background. Rural students also reported teachers as being supportive more frequently than urban students. Conclusion. Universities should consider ensuring that student support is relevant. Results indicate that students from rural backgrounds access academic, financial and social support from various sectors but rely most on peers who know and understand their context, family and the broader community ‘back home’. It is important for universities to consider the type and nature of support that students need in order to address gaps in support programmes.

Abstracts Assessing the efficacy of posters as educational intervention for paediatric sample collection in forensic pathology practice at the Tygerberg Medicolegal Mortuary H la Grange,* J Verster, A Louw, V Thompson, J Bezuidenhout, J Dempers, C de Beer *hlg@sun.ac.za Background. Published literature in South Africa focusing on investigations into sudden unexpected death in infants (SUDI) is limited. Such studies are further restricted by the lack of a universally recognised SUDI investigation protocol for South Africa. Challenges to facilitate training of Forensic Pathology Officers (FPOs) in SUDI specimen collection to assist SUDI investigations include personnel shortage and work rotations. Although FPOs receive basic training in collection of autopsy specimens, the need was identified for further training in the collection of special swabs for the purposes of an ongoing study of virological infections. As an adjuvant to training, specimen collection procedures were indicated algorithmically on a mini-poster and introduced in the Medico-legal Mortuary. Objective. To determine the efficacy of instructional mini-posters in guiding FPOs with SUDI autopsy specimen collection procedures. Method. This was a qualitative, retrospective, pre- then post-assessment study conducted at the Tygerberg Medico-legal Mortuary in Cape Town, South Africa. FPOs were evaluated with a questionnaire and focus group session to determine the efficacy of the mini-posters placed at this centre. Results. Preliminary observations indicated that posters, in isolation, were ineffective in guiding SUDI autopsy procedures. Continuous verbal guidance was frequently required during the course of the sample collection procedure. Therefore it became apparent that different approaches are needed to increase awareness and adherence to the poster content in order to effectively guide SUDI specimen collection procedures. Conclusion. Effective strategies are required to improve awareness of instructional posters to streamline standard SUDI autopsy specimen collection procedures. This urges the need for larger follow-up studies to aid in the development of a more structured and feasible forensic pathology service training programme in the Western Cape. Final-year MB ChB assessment mapping: What value does this add? C P L Tan,* S C van Schalkwyk, F J Cilliers *tanplchristina@gmail.com Background. In high stakes examinations, tests of clinical competence, which allow decisions to be made about medical qualifications and fitness to practise, need to provide reliable and valid measurements of student performance. There is an extensive body of literature devoted to the challenges of clinical assessment. There are also widely accepted criteria for sound assessment. At Stellenbosch University, there is also an assessment policy to provide a framework and to bring the assessment practices of the University in line with current, research-based views and standards regarding assessment. An investigation was undertaken to determine what current assessment methods are being used at exit level in the Bachelor of Medicine and Bachelor of Surgery (MB ChB) programme at Stellenbosch University and how these assessment methods are described in official module documents. Objective. To map what assessment methods are used and how they are used in the exit level MB ChB programme at Stellenbosch University, as described to students in relevant documentation.

Method. Document analysis of study guides for exit-level modules was done for information relating to methods of assessment and their use. Assessment methods, divided into written and non-written formats, were mapped on an Excel spreadsheet against modules to provide an overall view of assessment for all final-year modules. Results. Assessment practice varied across modules based on (i) the approaches and number of assessments; (ii) weighting of individual components; and (iii) the use of assessment tools. Conclusion. Mapping the assessments can provide a useful reference overview for module and programme co-ordinators. The next step in this research would be to determine if there is sound assessment taking place and would provide some indication of the degree of alignment with the Stellenbosch University Assessment Policy as well as with international criteria. Evaluating the knowledge of clinical teachers required to implement OSCE as an alternative clinical assessment method at the Catholic University of Health and Allied Sciences (CUHAS) in Mwanza, Tanzania R Kabangila,* J van Wyk *rodking20012000@yahoo.com Background. Long and short case clinical examinations have been traditionally and widely accepted as a means of clinical skills assessment in various institutions. However, using both methods at CUHAS with more than 700 students and only 45 clinical teachers, these methods are usually time intensive to both students and teachers alike. The Objective Structured Clinical Examination (OSCE) which is more objective is not used as a method of assessment at CUHAS. Objective. To assess the knowledge of OSCEs among clinical teachers required to implement this as an alternative clinical skills assessment method at CUHAS. Method. We conducted a cross-sectional study among clinical teachers from 4 clinical departments (Surgery, Gynaecology, Paediatrics and Internal Medicine). Data were collected using a pre-tested structured questionnaire. Simple analysis of the data was done. Results. A total of 34 questionnaires were distributed and there was a return rate of 82%. The majority of respondents (68%) were junior faculty (assistant lecturers and tutorial assistants). Median age of the respondents was 35 years (range 28 - 55 years). Although 96% of respondents had heard about OSCE before and 71% heard about it in the medical school, the proportion of respondents who were able to write in full what the term ‘OSCE’ stood for was only 58%. Sixty-three per cent of the respondents were not able to define basic concepts of assessment, including validity and reliability, and 60% were not able to state the types of skills that OSCCE can assess. Conclusion. Clinical teachers require training to use OSCE effectively as an assessment method. A dashboard for monitoring hospital practice for third- and fourth-year medical students at Wits University D Mandić,* D Prozesky *ddragan.mandic@wits.ac.za Background. Following anecdotal reports of problems in programme delivery a comprehensive evaluation of clinical teaching in years 3 and 4 was carried out (Cassim, 2009). Despite the implementation of improvements many problems still persisted.

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Abstracts Objective. The Hospital Day dashboard initiative aimed to monitor and improve third- and fourth-year medical students’ clinical teaching during hospital and community site visits. The strategy was developed by having transparent weekly feedback from students about each clinical site. Method. Weekly student surveys were carried out over a period of five months. Data collection questionnaires were developed, allowing quantitative and qualitative evaluation. The results were analysed and widely distributed weekly in dashboard format. Problems identified were individually followed up and rectified. Results. The weekly performance reports to all stakeholders resulted in progressive and significant improvement in the educational quality of the events, as well as greater satisfaction among the students. The report format made it possible to identify specific weaknesses and remedy them without delay. Some of these weaknesses were found to be administrative, such as poor communication, resulting in students and tutors not meeting as planned, specific transport problems, and monitoring of student attendance. Others were educational: unsystematic skills teaching and one-way lecturing, and students not using their initiative and expecting to be spoon-fed. Conclusion. There is a clear need for transparent and meticulous weekly follow-up in such programmes. As a result of the ‘dashboard’ system student satisfaction, student attendance and quality of clinical teaching are being advanced. Clinical training of third- and fourth-year medical students benefits by thorough, continuous and transparent weekly surveys. Writing and its significance to problem-based learning research: An innovative way of contributing to medical education research K Bryant,* M Kebaetse, M Mpho, O Nkomazana *katie.bryant@mopipi.ub.bw Background. Medical education research illustrates that medical schools experience benefits and challenges in both implementing and using problem-based learning (PBL) curricula. In terms of the challenges, studies tend to highlight one of two themes: those related to teaching and learning or those related to institutional implementation. In the context of developing countries, particularly the context of various African countries, as new medical schools open and implement PBL or hybrid curricula, research is also beginning to emerge on this issue; yet, most of these studies focus on implementation as opposed to teaching and learning-related challenges. Interestingly though, the University of Botswana’s recently opened School of Medicine (UBSOM) has identified and started to investigate a teaching and learning challenge potentially connected to its use of a PBL curriculum. This challenge is the difficulties first-year medical students have writing for PBL purposes. Objective. To present preliminary findings from this study at UBSOM to demonstrate how studying the activity of writing, specifically the writing challenges of first-year medical students, can uncover particular teaching and learning challenges that emerge from using a PBL curriculum Method. Situated in the qualitative research paradigm, and using a constructivist grounded theory methodology, these findings come from interviews with UBSOM’s first-year PBL teaching staff and purposively sampled first-year medical students. The interviews focused on both groups’ perceptions of first-year medical students’ challenges writing for PBL purposes. Results. The discussion will focus on overarching themes emerging from interviews with teaching staff and students about the challenges medical

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students experience writing for PBL purposes. These themes will be connected to larger teaching and learning challenges emerging from the literature about using PBL curriculums in medical schools. Conclusion. Investigating the writing-related challenges of medical students can highlight important teaching and learning challenges that come from implementing and using PBL curriculums in medical schools. A South-South elective: Helping to establish a role for family medicine in Rwanda M Flinken-Flögel,* G A Ogunbanjo *maaike.cotc@gmail.com Background. Postgraduate education in Family Medicine in Rwanda started in 2008. Family medicine does not yet have a place in the Rwandan healthcare system and residents are therefore unsure about their future professional role. Therefore, when offered the opportunity, five out of six Rwandan final-year residents selected a 4-week elective in South Africa to experience family medicine. Objective. To explore how an elective in South Africa adds value to the Rwandan postgraduate family medicine training. Method. An existing bilateral co-operation facilitated the establishment of a 4-week elective at Limpopo University, South Africa. A qualitative descriptive study was conducted, doing semi-structured individual interviews with all five residents who completed the elective. Interviews were transcribed and inductive thematic analysis was undertaken. Results. Residents’ purposes for the electives were to increase knowledge of and gain practical experience in several areas. These areas were divided into patient care, the South African health are system, family medicine in the South African setting and postgraduate family medicine education in South Africa. The last purpose was to identify useful aspects to implement in the new Rwandan family medicine context. Most knowledge-related purposes were met and the elective was considered to have added good value. However, purposes in practical skills were not met. Residents also reflected that due to contextual difference, not everything observed could be applied in the Rwandan setting. In addition to residents’ purposes, interviews revealed that the elective increased their confidence as family physicians and enhanced their attitude towards family medicine as a profession in Rwanda. Conclusion. A South-South elective in an African country with an established role for family medicine can add value to a Rwandan family medicine curriculum. Experiencing the role of family medicine in the South African healthcare system enhanced Rwandan residents’ sense of professional identity. Adapting the format of the elective to the Rwandan context will further enhance this learning opportunity. Quality improvement projects as a way to achieve transformative learning M Bac* *jannie.hugo@up.ac.za Background. Medical and BCMP students at the University of Pretoria are required to do a Quality Improvement Project (QIP) during their final year of study. Every year 200 medical students do their community obstetrics and family medicine rotation in district hospitals and clinics in Gauteng and Mpumalanga. Each group of students is required to do a QIP in their Clinical Learning Centre (CLC). Clinical Associate students spend a full

Abstracts year at a CLC, usually in a district hospital, and are also required to write an assignment on the functioning and performance of an aspect of the health services. Method. In this way about 250 students are involved in the assessment of the health services and become actively involved in the analysis of the weak and strong points of healthcare delivery. After a study of the relevant literature, an intervention plan is made that has to be presented to the local health team that is responsible for this service and has to implement the recommended improvements. Results and Conclusion. Medical and Clinical Associate students can be involved in transformative learning by doing QIPs and become important team members of an on-going quality improvement spiral in district hospitals. In this way learning is no longer informative or formative but transformative and in line with the recommendations of the Lancet Commission report. Designing a faculty development workshop on integrating research into teaching and learning J M Frantz,* A Rhoda, J de Jongh *jfrantz@uwc.ac.za Background. A paucity of information regarding the impact of faculty development initiatives to improve the integration of research into teaching and learning exists. Many academics do not possess the knowledge and skills to integrate research into teaching and learning, and faculty development in this area is therefore required. Workshops can be used to develop academics’ understanding of the strengths and limitations of incorporating research into teaching and learning, as well as to give them an opportunity to apply knowledge gained in their practice of teaching modules. Objective. To describe the procedures that were used to plan and implement a faculty workshop related to integrating research into teaching and learning. Method. The ‘backwards instructional design’ was used to plan the workshop. This design aims to address three main questions: what does an accomplished learner know?, How does a learner demonstrate their knowledge?, and What activities will provide an opportunity for practice and ‘uncovering’ knowledge? The description of the faculty development programme will be focused on the guiding principles for the backward instructional design and the content. Results. Backward design uses a question format rather than measurable purposes to identify desired results of the workshop. By answering key questions, participants deepen their learning about the content and experience an enduring understanding. In addition, the facilitators formulated the questions with the desired outcome in mind. During stage 2 in the design process facilitators defined activities that will demonstrate that the participants acquired the knowledge, understanding and skill to answer the questions. Finally, stage 3 incorporated planning the learning experience that will equip participants to develop and demonstrate the desired understanding. Conclusion. Backward design assists facilitators to incorporate research findings in designing learning programmes that have clear goals and purposes and include activities that are aligned to these goals.

Evaluation of a research capacity intervention for academic staff within the Appreciative Inquiry Framework A Rhoda,* J de Jongh, J Blitz, J Frantz *arhoda@uwc.ac.za Background. The development of research capacity of health professionals could result in improved provision of healthcare. Evaluating interventions aimed at developing research capacity is vital to determine their value and need. As a framework used for organisational change, the Appreciative Inquiry framework is suitable for the evaluation of research capacity development interventions. Objective. To explore academic staff experiences of a research capacity development intervention in the Faculty of Community and Health Sciences at the University of the Western Cape using the Appreciative Inquiry framework. Method. This study used a qualitative contextual exploratory design. All the academics that had completed a research capacity development programme in the preceding year were approached to take part in the study. Five academics volunteered to participate in a focus group discussion which explored their experiences of the research capacity intervention. An interview guide was used to collect the data. Content analysis using the Appreciative Inquiry framework was used to analyse the data. Ethical clearance was obtained from the University of the Western Cape’s ethics committee. Results. The themes that emerged from the focus group discussions are presented according to the appreciative inquiry phases. Within the discovery and description phase were active contextualisation of teaching and learning concepts, emotion-based intrinsic factors related to the intervention, and interaction with facilitators. Within the dream phase the participants visualised the need for continued mentorship and support. Within the designing and destiny phase were recommendations relating to the content and format of the intervention. Conclusion. Analysis of the focus group discussion using the Appreciative Inquiry framework highlighted that while the capacity development intervention had been a very positive experience, there was still room to develop post-intervention support initiatives to help faculty cope with the disablers encountered in their everyday work environment. Participating then using: What gets the academic racehorse to the faculty development water trough and what makes it drink? F Cilliers,* N Herman *francois.cilliers@uct.ac.za Background. Much advice about faculty development (FD) practice is based on intuition, experience and isolated empirical evidence rather than being grounded in a conceptual framework (CF). To be useful, a CF for FD would need to address human behaviour in a complex social context. Health behaviour theory (HBT) does this. Eaton et al. (2003) proposed a CF relating inter alia to personal factors, interpersonal factors and organisational factors as influences on behaviour. Objective. To explore the utility of a CF drawn from HBT to understand the participation of academics in FD initiatives and their subsequent application of what they learn.

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Abstracts Method. Structured interviews were conducted with 14 purposively sampled academics. Interview data and concepts from a HBT informed the design of a questionnaire. A total of 495 academics who had participated in an FD retreat over a 12-year period were surveyed using closed-ended and open items. Results. A total of 246 academics (49.7%) responded. Participation was influenced more strongly by personal and organisational factors than by interpersonal factors. Personal factors included intrinsic motivation and perceived utility of activities. Organisational factors included workload (administrative and teaching) and pressure to do and reward for research. Utilisation was also influenced more by personal and organisational, than interpersonal, factors. Utilisation was enabled by intrinsic motivation, perceived utility and feasibility of ideas and a departmental climate supportive of teaching. Utilisation was hindered by workload (administrative, undergraduate teaching, research and postgraduate teaching), but not by a lack of either confidence or a sense of self-efficacy. Conclusion. While the HBT CF proved useful, qualitative data we collected added dimensions to our results that transcended those of the CF used. Our data align better with a recently published refinement of a model of the transfer of training. Applying CFs should contribute to the design of conceptually stronger FD programs. Time to get online: Ibadan postgraduates root for distance learning M D Dairo* *drdairo@yahoo.com Background. The Master of Public Health (MPH) degree is a mandatory requirement for appointment of public health officers in both the private and public health sectors in Nigeria. Unfortunately, admission has been limited owing to infrastructural constraints. Delivery of the MPH curriculum as distance learning offers a solution. Objective. This study examined the feasibility and acceptability of a distance learning MPH programme to applicants as a necessary condition to determine its introduction in the institution. Method. A self-administered questionnaire was used to collect data on demographic variables, nature of employment, desirability of a distancelearning module and motivation to enrol for a distance-learning MPH programme. Results. Many applicants (40%) are engaged in paid employment and 67.8% worked 6 - 8 hours daily. Applicants indicate access (96.5) to personal computers, mainly laptops (92.9%). Internet access ranges from all day (45.4%) to only 2 - 3 hours daily (8.5%). Most applicants access the internet at home (35.5%), at both home and office (22%) and by mobile telephone devices (24.8%). Most considered themselves skilful (95.1%) in its use. About 49.6% of the applicants have previous experience accessing online instruction and are willing (84.4%) and enthusiastic (75.9%) to receive online modules of instruction. About half (53.9%) consider such modules effective and of the same quality (50.4%) as traditional learning. Reasons for preferring online instruction include inconveniences of large classes (50.4%), ease of learning (16.3%) and having other commitments (14.9%). Blended audiovisuals with written modules (53.9%) is the preferred online mode of course delivery. Conclusion. The findings from this study indicate that infrastructural capacity and attitudinal disposition to uptake of online mode of instruction are high among applicants to the MPH degree programme. Institutional

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policy change and curriculum development are therefore required to exploit the opportunity. Postgraduate students’ perception of online learning in a selected nursing education institution in KwaZulu-Natal V Mdunge, N Mtshali, S Mthembu* *sindizama@gmail.com Background. Online learning is becoming an indispensable complementary teaching and learning tool and has been an integral aspect of education in many tertiary institutions around the world. In nurse education and training, online learning, web-based learning or e-learning is a fundamental necessity, especially in the light of the growing shift into information and communication technology (ICT). Objective. To explore the online learning experiences of postgraduate nursing education students at a selected nursing education institution in KwaZulu-Natal. Method. A qualitative exploratory design was used. Data were collected through semi-structured interviews from 16 postgraduate nursing education students and thematic data analysis was used. Ethical approval to conduct the study was secured from the University Ethics Committee. Results. Themes that emerged focused on specific areas – engaging with information technology, online learning process, facilitator’s role and expertise, knowledge construction process, empowerment personally and academically, challenges and recommendations. The role and expertise of the online facilitator emerged as critical in guiding, supporting the learning process and ensuring that all participants engage in the learning process to facilitate intensive learning. Intensive engagement with learning material before the online session, engaging with and critiquing work posted online by peers, the process of generating new knowledge or contextdriven knowledge, easy access, convenience and flexibility in terms of time emerged as benefits associated with online learning. Asynchronicity and flexibility regarding time to engage with online content, availability of a facilitator to engage with students online, financial cost and technical expertise emerged as challenges. Conclusion. Although a large majority of participants had never taken an online class prior to this course, the overall perception of online learning was positive. The positive aspect outweighed the negative aspects. Online learning is a worthwhile experience that facilitates personal and academic development. The neglected grass-root adoption of mobile phones as learning tools in resource-limited settings: A study from advanced midwifery education in KwaZulu-Natal, South Africa P Brysiewicz,* C Pimmer, U Gröhbiel, F Walters, S Linxen, J Chipps *brysiewiczp@ukzn.ac.za Background. Many m-health and m-learning interventions fail, because they adopt a technocentric view and ignore the local context. Objective. To address the above, the present study investigated the ‘organic’ adoption and educational usage of mobile phones by health workers in rural health settings. Method. A qualitative study was conducted, interviewing nursing/advanced midwifery students, facilitators and nursing managers from rural, resourceconstrained regions in the province of KwaZulu-Natal, South Africa.

Abstracts Content analysis used the concepts of Community of Inquiry theory as ‘a priori-constructs’. Results. The research revealed a number of unexpected learning and teaching practices, based on the grass-root adoption of mobile phone functions and in particular social apps. These practices involved cognitive, teaching and social presence as well as reflective practice and enabled rich educational experiences – according to the Community of Inquiry Theory. Theoretical discussion: ‘Traditional’ communities of inquiry are based on predetermined online environments. By contrast, learners used bundles of phone-based functions/apps to embed mobile and blended communities and other resources that were fragmented across social, temporal, topical, geographical, digital and ‘real’ spaces in the inquiry process in very dynamic ways. Conclusion. In view of future mHealth and mobile learning efforts, mobile phones appear to be particularly suitable to facilitate competence development in the following ways: (a) problem solving and situated co-construction of local knowledge; (b) sociocultural participation – to alleviate professional isolation; (c) connecting learning in workplaces with formal education systems; and (d) addressing unpredictable opportunities and challenges that are typical for the changing and provisional (health) contexts observed. Instead of ignoring the revealed practices, health and education institutions are well advised to support learners in media literacy, enabling them to more effectively and critically use existing (mobile) technologies. Enhanced video podcasting and its potential for transformative learning S Walsh,* M de Villiers *walsh@sun.ac.za Background. To assist our students with learning, we created enhanced podcasts of all the second-year MB ChB lectures during 2012. Our study used enhanced non-segmented podcasts with a conceptual focus for receptive viewing. Method. The lecturer’s PowerPoint slideshow together with the audio of their lecture was converted into an enhanced podcast (video) of the lecture and placed on the Blackboard Learning Management System for the class to view and download. Data were collected by means of a questionnaire and a focus group to evaluate the intervention. Examination results from 2012 were compared with those of previous classes. Results. Ninety-five per cent of students rated the podcasts as beneficial or extremely beneficial. Our students came up with a novel uses of podcasts: playing the podcast at 1.5 times its normal speed; podcasts benefited with language issues; they could evaluate the quality of the lecture; and object to test questions they felt were unfair because the content was not covered in class. One of the major hurdles we had to overcome was how podcasting impacts on copyright and aspects of this are discussed. Feedback from our lecturers and the student’s focus group indicated that podcasts did not result in significant non-attendance of classes. Conclusion. The medical curriculum is acknowledged to suffer from information overload. Our students mostly found podcasts beneficial for clarifying concepts they did not grasp in class. The feedback provided useful pointers for improving the process and has resulted in all podcasts being made available online to all students and faculty. We see the podcasts as one of the foundational enablers in implementing transformative learning, as podcasts can facilitate the flipped classroom approach.

Out-of-the-box teaching: Teaching for different learning styles D Mtyongwe,* K M Mpeko, M Raphuthing *dmtyongwe@cut.ac.za Background. Historically, teaching has been left to the interpretation of the respective teacher, creating as many views and methods as there are teachers. Traditionally, the way the teacher learns becomes the way they view learning, which impacts on the way they teach. In essence ‘we teach students to receive information, the way we believe information is received’. What determines how information is received is thus influenced by the learning style of the individual. Learning styles in this context are referred as classed in the VAK Learning Styles Self-Assessment Questionnaire, viz. visual, auditory and kinesthetic. These learning styles promote successful lifelong learning, as the focus is on how you learn rather than what you learn. There are those students whose learning needs are not met by traditional teaching methods; and this has created the birth of innovative teaching methods. Objective. To introduce learning styles in higher education and review the relationship between the application of learning styles in order to address the shortfalls of traditional teaching by introducing innovative teaching methods. Method. The study covered two programmes: clinical technology and dental assisting in the Faculty of Health and Environmental Sciences. A total of 76 first-year students participated and completed a VAK Learning Styles Self- Assessment Questionnaire which addressed their learning styles. Results. The data revealed 28 visual, 15 auditory, 30 kinaesthetic, and one with an equal score in all categories and one who scored equal in auditory and kinaesthetic. Conclusion. The majority of the students are kinaesthetic and visual so the teaching elements in both programmes need to consider the needs of these students. It’s important to know learning styles to be able to address student needs and innovative teaching must be introduced for shortfalls discovered. The effect of teaching methods used as experienced and perceived by student nurses at a nursing college in the Western Cape Province L Furst,* E Stellenberg *lfurst@sun.ac.za Background. The 21st century teaching environment is unique in its diversity, and challenges academic staff to create a teaching environment that is conducive to all current learners. Various teaching methods are available and affordable, but technology remains an essential investment for the future of higher education institutions. Objective. To evaluate the perceptions of student nurses regarding the effectiveness of the teaching methods which they experienced at a nursing college in the Western Cape Province. Method. An explorative, descriptive research design with a quantitative approach. The target population of 1 238 nursing students following the R425 programme. Stratified random sampling selected the sample of participants (n=267). A self-administered questionnaire with predominantly closed questions was personally administered by researcher. Results. Results include a significant difference in generation X participants and the green/whiteboard teaching methods (Spearman p=0.02) and their preference of the traditional lecture as a teaching method (Spearman p<0.01). The perceived effectiveness of the teaching methods on student

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Abstracts performance varied between very helpful and not helpful. Only 49 (19%) of participants experienced the traditional lecture as being very helpful on their general academic performance compared with the effect of group work (n=69; 26%) and self-activity (n=102; 39%). Open-ended questions showed that participants regarded the teaching strategies as boring and ancient and that much of the unhappiness expressed stems from the difference in the needs of millennials and the lack of change and obstinacy existing among academics. Conclusion. Should recommendations be implemented, a complete transformation of the college under study will result. It may force the education institution to move out of complacency, to a more vigorous and dynamic education environment that enables them to emerge as a Higher Education Institution (HEI) of good standing. Recommendations include an increase in the use of technology, a blended approach to teaching, the re-training of academic staff, and measures in counteracting a boring classroom environment. Nursing students’ experiences using simulation as a clinical teaching method in South Africa N Nel,* E Stellenberg *natalievdmerwe@sun.ac.za Background. Given the pivotal role that simulation plays in teaching students clinical skills, it is important to understand the experience students have utilising simulation laboratories. Objective. Exploring the experience of primary healthcare students utilising simulation laboratories. Method. A descriptive qualitative research design was applied. Purposive sampling of 10 individual interviews and a focus group of seven participants was drawn from the primary healthcare students who successfully completed the programme the preceding year. Data were collected by two trained fieldworkers and transcribed by the researcher. Ethics approval was obtained from the Stellenbosch University and informed consent from the participants. Results. These showed that the students are in favour of simulation as a foundation phase in their programme but preferred to be introduced to an actual human being. ‘ ... it already began laying the foundation to work with the patients and stuff. It gives reassurance that you at least know something.’ Students felt more confident and competent after practising on human beings. Member checking was done to determine the validity of data analyses. Conclusion. Simulation as a clinical teaching method ensured a good foundation phase, but students felt more competent and confident after practising on human beings. The use of mannequins for the foundation phase should be maintained. However, the introduction of human beings for students to practise on after practising on a mannequin should become part of the learning opportunities. Multidisciplinary learning: Joint patient encounters with undergraduate medical and pharmacy students S de Johnston, S Moch, F Oluwafolajimi,* L Green-Thompson, P Mc Inerney, P G Shiba *oluwafolajimi.fadahun@wits.ac.za Background. Multidisciplinary approaches in the education of pharmacy and medical students have had reported benefits. Medical students are perceived to have stronger diagnostic skills while pharmacy students are

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seen to have superior medication knowledge. The Wits Faculty of Health Sciences offers degrees in both pharmacy and medicine on the same campus and is therefore in an ideal situation to implement and assess interdisciplinary learning encounters between these two groups of students. Objective. To, firstly, implement combined clinical learning opportunities where medical and pharmacy students would jointly see patients and, secondly, establish the students’ perceptions of these joint learning opportunities. Method. A total of 45 registered students comprising 15 final-year pharmacy students and 30 third-year medical students were invited to participate in the joint patient encounter. Fifteen groups were formed from the pool of participants. Each group consisted of two medical students paired with one pharmacy student. The students remained in these groups for the 8-week period of the study at Charlotte Maxeke Johannesburg Academic Hospital. During the study, they jointly assessed patient records and participated in the patient consultation, guided by a supervising doctor. Students who participated in the encounter were invited to attend a discipline-specific focus group discussion where they shared their perceptions and experiences. The two discipline-specific focus groups were asked the same primary and probing questions by interviewers. Results. Three themes were identified: the meeting of professions, the value of the shared experience, and the patient as a source of learning. Conclusion. There are potential benefits for both healthcare professionals and patients when adopting multidisciplinary approaches in teaching and learning. Introducing a novel assessment instrument designed to address students’ Xhosa language skills in the clinical consultation M du Plessis,* C Tan, P Lewis M de Villiers *mads@sun.ac.za Background. In 2011, Stellenbosch University Faculty of Medicine and Health Sciences (SUFMHS) embarked on a new initiative in teaching students language in communication with patients so as to improve healthcare service delivery. This includes the implementation of Xhosa and Afrikaans courses in the undergraduate programmes, starting with the Bachelor of Speech-Language and Hearing Therapy and Bachelor of Science in Dietetics degrees. As the focus for students is on learning how to communicate competently in a clinical context, there is also a need to develop effective and appropriate assessment instruments. Objective. To refine an existing assessment instrument in order to make it more appropriate for the purpose of assessing language of communication skills in a clinical context, and implement its use at SUFMHS. Method. An assessment instrument, with emphasis on assessing a student’s ability to incorporate relevant clinical skills in a communicatively competent manner, was refined and developed jointly by linguists and clinicians. This is used to assess Human Nutrition students in role plays with simulated patients. Simulated patients are also required to assess students on aspects they consider important for improving quality of patient care. Students, lecturers and simulated patients are then surveyed on their perceptions of the newly refined assessment instrument to gauge its acceptability. Results. This is an ongoing study. The process of refining, developing and implementing the assessment instrument is described. The assessment by the simulated patients, as well as the responses from the survey, will be summarised and documented.

Abstracts Conclusion. This study is striving towards further development of this novel assessment instrument designed to address students’ Xhosa language skills in the clinical consultation. Interprofessional participation and collaboration has been critical in the refinement and development of this assessment instrument. Putting the click into clickers: A novel formative assessment approach developed for isiXhosa clinical communication L Mhlabeni,* P Lewis, M de Villiers *lmhlabeni@sun.ac.za Background. The necessity to improve the increasing communication challenges experienced among health professionals and patients is a focal point in the South African multilingual society. This predicament is currently being addressed by many universities in the country. Stellenbosch University Faculty of Medicine and Health Sciences (SUFMHS) has embarked on numerous innovative initiatives to develop and improve students’ clinical communication proficiencies with non-language concordant patients. This presentation reflects on the development and application of student response systems (SRS) as a formative assessment tool in isiXhosa teaching and learning interventions. Objective. This presentation aims to demonstrate the design, development and application of this technologically based tool to assist with clinical consultation assessment procedures in learning isiXhosa and to prepare students for simulated OSCEs. The implementation is informed by a study designed to investigate students’ user-satisfaction and application of the SRS platform for isiXhosa. Method. Experiences with the development and application of SRSs used in isiXhosa formative assessment procedures together with its strengths and challenges are reported by the presenter. This project is also informed by a pilot study focusing on students’ and lecturers’ user-satisfaction views on this alternative assessment approach. Results. Fifty Occupational Therapy first-year students have been identified to participate in this pilot study. The findings of the study will be available by October 2013 and will open avenues to further analyses to improve the application of future SRS-related developments as well as envisaged endeavours to support and reinforce students’ isiXhosa communication skills. Conclusion. South Africa is faced with huge language barriers in the healthcare sector. We trust that by developing this novel formative assessment approach for isiXhosa teaching and learning we will be able to contribute towards enhancing the learning of an African language for health professionals in order to improve quality patient care in our health services. Supervisor-student engagement: Do we ask the right questions? H Friedrich-Nel,* J Mac Kinnon *hfried@cut.ac.za Background. The roles and responsibilities of the research supervisor are not universally agreed upon, and so this is an area that creates active debate in the literature. The function of the research supervisor is to assist the student in completing a script, a dissertation or a thesis and by doing so attain the outcomes of research. The supervisor also has to provide ‘information to transformation’ to support the student in becoming an

independent professional researcher and scholar as well as develop critical thinking and problem-solving abilites. Objective. The question was if the right questions are asked during research supervision so that outcomes such as critical thinking and problem solving are attained. Method. A qualitative study exploring the perceptions of supervisors was conducted at a university of technology as a case study. Postgraduate research supervisors in the Faculty of Health and Environmental Sciences responded to an e-mail request to provide details of their approaches in postgraduate supervision. Content analysis was used to analyse the data. Concepts were created and grouped according to sub-themes. Results. Three themes emerged from the data collected from the supervisors who responded, namely the mechanics of the supervision, the environment in which the supervision was performed, and the attitude of the supervisor. Additionally, supervisors indicated a preference for discourse rather than just feedback, a preference for face-to-face meetings and that feedback needs to be regular. Conclusion. Supervisors were silent about challenging the students to facilitate critical thinking during the feedback sessions. The postgraduate supervision process should aim to transform the student into an independent scholar, attain the research outcomes and encourage critical thinking and problem solving. For this reason the right questions need to be asked. A patient’s experience of critical illness: Informing those who cure/care C Drenth* *nelia@phca.co.za/neliad@wol.co.za Background. Critical illness, admission to an intensive care unit and prolonged hospitalisation all impact on the psychosocial functioning of an individual. Objective. There is a dearth of qualitative studies on the patient’s psychosocial reactions to critical care. In this presentation I explore my own experience as a critically ill patient (being hospitalised for 127 days) and the recovery from this illness. Method. I conducted an auto-ethnographic study to add knowledge to the scarcity of research from the patient’s point of view. In auto-ethnography the researcher draws on his/her own lived experience and makes a connection between the self and others within the same context. Results. The following themes were identified from the data: uncertainty and the need to be kept informed, pain and suffering, meaning making and post-loss growth, and a whirlpool of emotions. My experience as a social worker in healthcare for more than 30 years certainly brought with it an understanding of some issues impacting on the patient who experiences a critical illness. Being dependent on the doctors’ calls, care of nursing staff and dependency on my husband after discharge influenced my self-image. I feared being alone and was trapped in my own small world of uncertainty. The themes emerging from the data may not be new, but certainly emphasise the importance of this knowledge for the interdisciplinary team engaging in the world of the critically ill patient. Conclusion. Psychosocial care for patients in intensive care has lagged behind because of physical problems. The importance of monitoring the ICU patient’s psychosocial outcome and not just their physical outcome is highlighted by several authors and confirmed by my experience. My experience of critical illness leads to recommendations for care of the patient in ICU.

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CPD

NOTIFICATION

Dear CPD client, We wish to take this opportunity to thank you for your continued support through the completion of our online CPD questionnaires as well as to share some exciting news with you. HMPG’s journal CPD questionnaires will be moving to the Medical Practice Consulting (MPC) CPD platform (www.mpconsulting.co.za) as part of a strategy to consolidate all South African Medical Association (SAMA) members’ CPD certificates and history. All SAMA CPD certificates (whether for annual conferences, branch meetings or workshops) are already available online on the MPC CPD platform and moving all active HMPG online CPD questionnaires to the same platform will mean that all SAMA member CPD certificates will be issued in one central, convenient location – resulting in less admin for our CPD clients. An additional benefit is that the MPC CPD manager can complete your IAR form on your behalf (no more countless hours of reconciling CPD records before a compliance audit) and submit your CPD history to the HPCSA once you have approved it and are happy with the results. All that is required of you, when you are ready, is to click a single button to submit your CPD Activity Record to the HPCSA. Nothing will, of course, ever be submitted without your prior approval and consent. The MPC system also adds additional functionality to the CPD questionnaires and the system has been set up to make the process as easy to follow as possible. The South African Medical Association (SAMA) board has concluded that the CPD services associated with the South African Medical Journal (incorporating Continuing Medical Education) and the South African Journal of Bioethics and Law will only be offered to registered and fully paid-up SAMA members, as per the SAMA member benefit schedule; therefore, you will be required to register a profile on the MPC CPD system (if you do not already have one – if you already have one, login as usual) and to supply your SAMA membership number. You will be required to do this only once. Your membership will be validated in real-time and you will be able to access the journal CPD questionnaires. This once-off registration should not take more than 2 minutes and you will be on your way to completing the CPD questionnaires. Below are some questions and answers that will assist you in getting started.

When will the CPD questionnaires move to MPC? All HMPG-issued journal CPD questionnaires will move to the MPC CPD platform from February 2014 onwards. This will include all prior CPD questionnaires that are still active.

What website do I access to complete the HMPG questionnaires? www.mpconsulting.co.za

Who is MPC? Medical Practice Consulting (MPC) is a group company of SAMA. MPC has historically hosted CPD at SAMA’s annual conferences, issued all SAMA member CPD certificates and has hosted SAMA’s online branch elections. By moving active HMPG journal CPD questionnaires to the MPC system, SAMA members will have all their CPD certificates in one central, convenient location. MPC has also been supplying the Foundation for Professional Development distance learning courses online for the last 2 years and has hosted some of the largest online training initiatives in the South African healthcare industry.

What do I need to register a profile on the MPC CPD system? MPC does not retain any confidential information on their database, so you will not be requested to share your telephone number, practice or home address. All that is required for registration is your name, surname, specialty, SAMA membership number and HPCSA number (which is included on your CPD certificate to comply with HPCSA CPD requirements).

How long will registration take? Completing registration should take no longer than 2 minutes – please remember to have your HPCSA (MP Number) and SAMA membership number at hand.

What about my historic CPD certificates on the www.cpdjournals.co.za website? If you register on the MPC CPD platform with the same email address as you were using on the www.cpdjournals.co.za website, MPC will import all your CPD certificates for the last 36 months into your MPC CPD manager for you. Alternatively you can still login to www.cpdjournals.co.za and save any CPD certificates that are still valid (remember that CEUs have a 24-month shelf life and expire after 24 months).

What happens if I run into technical difficulties? Simply complete an online contact form and MPC will assist you with your technical problem. If your SAMA number for some reason does not match that in the SAMA membership database, MPC will assist with rectifying the problem. MPC’s contact details are available online: www.mpconsulting.co.za/contact-us Sincerely, Gert Steyn CEO, Health and Medical Publishing Group (HMPG)

CPD Questionnaire May 2014 True (A) or false (B): The effect of an interprofessional clinical simulation on medical students 1. Interprofessional education takes place when medical students from different disciplines, for example Medicine and Psychiatry, participate together in a shared learning activity. 2. Good communication skills and teamwork skills are essential in learning activities that involve students from different healthcare professions. Are further education opportunities for emergency care technicians needed and do they exist? 3. Bridging programmes that address knowledge gaps play an important role by supporting articulation between diploma and degree qualifications in South Africa. How we see ‘Y’: South African health sciences students’ and lecturers’ perceptions of Generation Y students 4. G eneration Y students prefer visual rather than text data. Do physiotherapy students perceive that they are adequately prepared to enter clinical practice? An empirical study 5. Final-year South African physiotherapy students are better prepared for clinical practice from a generic skills, rather than an interventional skills, perspective. PIQUE-ing an interest in curriculum renewal 6. Medical graduates in South Africa may not be adequately prepared for the non-clinical roles they encounter as interns. Student doctors (umfundi wobugqirha): The role of student-run free clinics in medical education in Cape Town, South Africa 7. Attendance at student-run clinics, such as SHAWCO, is mainly motivated by a desire to serve the poor rather than the opportunity to obtain ‘hands-on’ experience. 8. More than 80% of students attending student-run clinics, such as SHAWCO, consider the clinics an ideal place to practise their language skills. Problem-solving abilities of radiography students at a South African university 9. The key attributes of clinical problem-solving are to: (i) understand the problem; (ii) plan an appropriate solution; (iii) carry out the plan correctly and logically; and (iv) evaluate the result. 10. Problem-solving skills may be developed by using role-play, video-taped simulation sessions, case studies and integrated assessments.

Introduction of a learning management system at the Kilimanjaro Christian Medical University College 11. Free learning management systems, such as Moodle, may be useful to deliver, assess and evaluate medical curricula. Medical and dental students' willingness to administer treatments and procedures for patients living with AIDS 12. Most Nigerian dental students (>80%) are willing to do dental extractions on HIV-positive patients. 13. Most Nigerian medical students (>80%) are willing to assist in surgery performed on HIV-positive patients. Understanding the learning styles of undergraduate physiotherapy students 14. It is essential to address the full range of learning styles of students when planning teaching and learning activities. Health-promoting schools as a service learning platform for teaching health-promotion skills 15. Service learning facilitates students’ learning by participation in random, opportunistic service experiences. 16. Service learning requires a structured opportunity for reflection after participating in a service activity. Using graduates as key stakeholders to inform training and policy in health professions: The hidden potential of tracer studies 17. Tracer studies of graduates may be a useful way of identifying policy needs that can improve healthcare services. The effect of characterisation training on the congruence of standardised patient portrayals 18. For standardised patients to be believable/congruent, real emotions, complementary verbal and non-verbal cues and gestures and appropriate use of voice and facial expression are required. Continuous professional training of medical laboratory scientists 19. The delivery of good healthcare in Africa is hampered by a lack of high-quality laboratory services owing to the limited availability of welltrained laboratory personnel. Physiotherapy clinical students’ perception of their learning environment: A Nigerian perspective 20. The provision of learning objectives at the beginning of a course allows students to take responsibility for their learning and become autonomous, self-directed learners.

A maximum of 3 CEUs will be awarded per correctly completed test. Effective in 2014, the CPD programme for AJHPE will be administered by Medical Practice Consulting: CPD questionnaires must be completed online at www.mpconsulting.co.za After submission you can check the answers and print your certificate. Questions may be answered up to 6 months after publication of each issue. Accreditation number: MDB001/016/01/2014 (Clinical)

May 2014, Vol. 6, No. 1 AJHPE

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