AJHPE Vol 7, No 1 (2015) by HMPG

AJHPE

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African Journal of Health Professions Education

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May 2015, Vol. 7, No. 1

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AJHPE

African Journal of Health Professions Education | May 2015, Vol. 7, No. 1

EDITORIAL

Is health professions education more about ‘doing’ rather than just ‘knowing’?

V Burch

FORUM

Strategies to include sexual orientation and gender identity in health professions education A Müller

SHORT REPORT

An ethical dilemma: A case of student training, intermittent service and impact on service delivery P Govender

RESEARCH

10 Developing an outcomes-based charter to direct teaching and assessment of medical professionalism R Delport, C Krüger, M van Rooyen, G Pickworth 16 The implementation of the Objective Structured Practical Examination (OSPE) method: Students’ and examiners’ experiences B Olivier, V Naidoo, W Mudzi, H van Aswegen, J Potterton, H Myezwa, R Roos, L Godlwana, D Maleka, S Mtshali, V Ntsiea, A Stewart, M Romm, C Humphries, B Watt 22 Students’ experiences of inter-professional education through International Classification of Functioningbased activities at a community-based rehabilitation centre M Kloppers, H E Koornhof, J Bester, F Bardien 26

Perceptions of physician leadership in Botswana L Sokol-Hessner, B M Tsima, C J Dine, B Masheto, J A Shea, J Masunge, O Nkomazana

32 Identity and attribution as lenses to understand the relationship between transition to university and initial academic performance W McMillan 39

The Human Rights Key: An innovative tool for teaching health and human rights in the health sciences V A Mitchell

Discovering the value of personality types in communication training for pharmacy students M J Eksteen, M J Basson

47 A lesson in listening: Is the student voice heard in the rush to incorporate technology into health professions education? L Keiller, G Inglis-Jassiem 51

Curriculum challenges faced by rural-origin health science students at South African medical schools P Diab, P S Flack, L H Mabuza, H Moolman

Learning approaches used by students in an undergraduate emergency medical care programme C Mosca, A Makkink, C Stein

Development of an evaluation matrix for a community-based interdisciplinary health-promotion course F Waggie

BOOK REVIEW

64 The Primary Health Care Approach and Restructuring of the MB ChB: A Case Study at the Faculty of Health Sciences, University of Cape Town

CORRESPONDENCE 65

Storymaking: An inter-professional learning experience M Swanepoel

CPD QUESTIONNAIRE

SUPPLEMENT 67

Medical education to strengthen health systems in Africa: MEPI as a catalyst for change

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 Sindiswe Mthembu University of the Western Cape Ntombifikile Mtshali University of KwaZulu-Natal Anthea Rhoda University of the Western Cape Michael Rowe University of the Western Cape Ben van Heerden Stellenbosch University Marietjie van Rooyen University of Pretoria Gert van Zyl University of the Free State Elizabeth Wolvaardt University of Pretoria

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Editorial Is health professions education more about ‘doing’ rather than just ‘knowing’? The 20th century Flexnerian approach to health professions education (HPE) focused on the need to provide healthcare professionals with a solid foundation of biomedical knowledge. While such knowledge will always underpin clinical practice, health professions educators in the 21st century are grappling with a much broader mandate – the professional behaviour/attributes of healthcare practitioners, i.e. professionalism. As suggested by Wilkinson et al.,[1] ‘professionalism is about what someone does, rather than what he or she knows.’ Miller’s pyramid,[2] intended to describe a hierarchical approach to assessment, also serves well in the context of professionalism – we need to move toward ‘doing’ and away from just ‘knowing’. On an international scale health professions training institutions and other key organisations, which train and accredit HPE programmes, have devoted a considerable amount of time and effort to defining the key aspects of professionalism and appropriate methods of assessment. Since this is an essential aspect of the training of health professionals in the 21st century we, as health professions educators in Africa, need to reflect on whether we are aligned with this mandate. A quick and simple ‘dipstick’ test to determine whether professionalism is on the agenda of health professions educators in Africa is to scan the education-related research output of our colleagues. Using a simple but comprehensive classification system,[1] which aggregates the desirable behaviour/attributes of healthcare professionals into five themes, it is easy to map out the articles in this edition of AJHPE and determine whether we are devoting sufficient time and attention to advancing the professionalism agenda in HPE. The key themes identified by Wilkinson et al.[1] include: • Adhering to ethical practice principles is the focus of two contributions: (i) Govender [3] from the University of KwaZulu-Natal (UKZN) reflects on the dilemma clinician-educators face every day, i.e. the tension between providing workplace-based training and clinical service delivery; and (ii) Mitchell[4] describes an innovative tool for teaching health and human rights at the University of Cape Town (UCT). • Effective interaction with patients and with people who are important to those patients is the focus of three papers: (i) Müller[5] from UCT writes about the need for including sexual orientation and gender identity in HPE curricula; (ii) Eksteen and Basson[6] from North-West University discuss the potential value that understanding personality types may have on improving communication between healthcare providers and healthcare practitioners; and (iii) Diab (UKZN) and colleagues[7] from Walter Sisulu University and Sefako Makgotha Health Sciences University (formerly MEDUNSA campus of Limpopo University) discuss the challenges that need to be addressed to ensure retention and success of rural-origin health sciences students who are likely to play a major role in the provision of healthcare in rural communities. • Effective interactions with other people working within the health system is addressed in three contributions: (i) Kloppers et al.[8] from Stellenbosch University (SU) report on students’ experiences

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of inter-professional learning at a community-based rehabilitation centre; (ii) Sokol-Hessner and colleagues[9] from the University of Botswana and the University of Pennsylvania discuss competencies perceived as important for physician leadership in Botswana; and (iii) Waggie [10] from the University of the Western Cape (UWC) describes a tool that could be used for evaluating community-based HPE courses. • Commitment to autonomous maintenance and continuous improve ment in the competence of self, others and systems is addressed in five papers that deal with teaching, learning and assessment activities that ultimately shape our lifelong learning and teaching habits: (i) Delport et al.[11] from the University of Pretoria describe the development of more explicit standards of professionalism, for teaching and assessment, using an outcomes-based approach; (ii) McMillan’s work, [12] from UWC, describes the relationship between transition to university and early academic performance for first-generation university students; (iii) Keiller and InglisJassiem[13] (SU) provide insights into the importance of students’ views about the rationale for implementation and appropriateness of technology used in blended learning experiences; (iv) Mosca et al.[14] provide insights into the learning approaches used by emergency medical care students at the University of Johannesburg; and (v) Olivier et al.[15] provide an overview of the opinions of students and examiners using a new assessment strategy at the University of the Witwatersrand. The remaining professional attribute described by Wilkinson et al.[1] is reliability, i.e. the need for healthcare professionals to be trustworthy, punctual, responsible, accountable and organised. While these attributes have not been directly addressed in this edition of the AJHPE they underpin all the encounters healthcare professionals have with their colleagues and the communities they serve. I am, therefore, of the opinion that if these attributes are neglected, the other attributes I have discussed lose their foundation and are rendered meaningless. My rapid overview of the current edition of the AJHPE demonstrates the potential utility of Wilkinson et al.’s thematic classification of the essential attributes of healthcare professionals. This user-friendly framework, as suggested by the authors, may serve as a valuable tool for blueprinting the multiple aspects of professionalism that need to be addressed in our teaching, learning and assessment activities as health professions educators in the 21st century.

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

Editorial 1. Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: Results of a systematic review. Acad Med 2009;84:551-558. 2. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65:S63-67. 3. Govender P. An ethical dilemma: A case of student training, intermittent service and impact on service delivery. Afr J Health Professions Educ 2015;7(1):8-9. [http://dx.doi.org/10.7196/AJHPE.405] 4. Mitchell VA. The Human Rights Key: An innovative tool for teaching health and human rights in the health sciences. Afr J Health Professions Educ 2015;7(1):39-42. [http://dx.doi.org/10.7196/AJHPE.366] 5. Müller A. Strategies to include sexual orientation and gender identity in health professions education. Afr J Health Professions Educ 2015;7(1):4-7. [http://dx.doi.org/10.7196/AJHPE.359] 6. Eksteen MJ, Basson MJ. Discovering the value of personality types in communication training for pharmacy students. Afr J Health Professions Educ 2015;7(1):43-46. [http://dx.doi.org/10.7196/AJHPE.370] 7. Diab P, Flack PS, Mabuza LH, Moolman H. Curriculum challenges faced by rural-origin health science students at South African medical schools. Afr J Health Professions Educ 2015;7(1):51-54. [http://dx.doi.org/10.7196/ AJHPE.390] 8. Kloppers M, Koornhof HE, Bester J, Bardien F. Students’ experiences of inter-professional education through International Classification of Functioning-based activities at a community-based rehabilitation centre. Afr J Health Professions Educ 2015;7(1):22-25. [http://dx.doi.org/10.7196/AJHPE.289] 9. Sokol-Hessner L, Tsima BM, Dine CJ, et al. Perceptions of physician leadership in Botswana. Afr J Health Professions Educ 2015;7(1):26-31. [http://dx.doi.org/10.7196/AJHPE.312]

10. Waggie F. Development of an evaluation matrix for a community-based interdisciplinary health-promotion course. Afr J Health Professions Educ 2015;7(1):58-63. [http://dx.doi.org/10.7196/AJHPE.432] 11. Delport R, Krüger C, van Rooyen M, Pickworth G. Developing an outcomes-based charter to direct teaching and assessment of medical professionalism. Afr J Health Professions Educ 2015;7(1):10-15. [http://dx.doi. org/10.7196/AJHPE.223] 12. McMillan W. Identity and attribution as lenses to understand the relationship between transition to university and initial academic performance. Afr J Health Professions Educ 2015;7(1):32-38. [http://dx.doi.org/10.7196/ AJHPE.356] 13. Keiller L, Inglis-Jassiem G. A lesson in listening: Is the student voice heard in the rush to incorporate technology into health professions education? Afr J Health Professions Educ 2015;7(1):47-50. [http://dx.doi.org/10.7196/ AJHPE.371] 14. Mosca C, Makkink A, Stein C. Learning approaches used by students in an undergraduate emergency medical care programme. Afr J Health Professions Educ 2015;7(1):55-57. [http://dx.doi.org/10.7196/AJHPE.393] 15. Olivier B, Naidoo V, Mudzi W, et al. The implementation of the Objective Structured Practical Examination (OSPE) method: Students’ and examiners’ experiences. Afr J Health Professions Educ 2015;7(1):16-21. [http:// dx.doi.org/10.7196/AJHPE.228]

Afr J Health Professions Educ 2015;7(1):2-3. DOI:10.7196/AJHPEnew.7896

May 2015, Vol. 7, No. 1 AJHPE

Forum Strategies to include sexual orientation and gender identity in health professions education A Müller, Dr med Gender Health and Justice Research Unit, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: A Müller (alexandra.muller@uct.ac.za)

Background. Sexual orientation and gender identity are not taught in African health professions curricula. In order to improve the quality of care for lesbian, gay, bisexual, transgender and intersex (LGBTI) patients, health professionals need to shift their attitudes towards sexual orientation and gender identity, and learn about specific LGBTI health needs. Discussion. The curricula of African health professions education provide various opportunities to include teaching about sexual orientation and gender identity. Various disciplines can teach sexual orientation and gender identity issues in their context by challenging heteronormativity and highlighting specific LGBTI health concerns, and can do so more successfully with interactive teaching approaches that hold more potential than formalised lectures. Rights-based teaching frameworks should include sexual orientation and gender identity as markers of difference. To achieve this, educators need to build capacity to teach about these issues, and support LGBTI students in their institutions. Conclusion. Teaching about sexual orientation and gender identity is urgently needed in African health professions education, but it is complex. This article presents strategies to incorporate sexual orientation and gender identity into the curricula of medical schools, nursing colleges, and the allied health sciences. Afr J Health Professions Educ 2015;7(1):4-7. DOI:10.7196/AJHPE.359

Social justice and equity are important principles in African health sciences education, leading to awareness of the social and economic determinants of health among our graduates. However, more forces of exclusion exist than our current curricula recognise. In this article, I review the health consequences of the social exclusion of lesbian, gay, bisexual, transgender and intersex (LGBTI) people. I then present a curricular framework for educators who are interested in teaching about sexual orientation and gender identity. A recent curricular review at the University of Cape Town’s Faculty of Health Sciences revealed profound gaps in teaching about sexual orientation and gender identity.[1] There is no evidence that the curricula at other South African (SA) or African health education institutions are significantly different. Sexual orientation and gender identity are not health hazards per se, but the social exclusion of LGBTI people leads to significant health disparities. Homophobia, the irrational fear and hatred of LGBTI people, and heteronormativity, a social construct that makes LGBTI identities invisible and assumes that heterosexual relationships are the norm, are powerful constructs that have direct and indirect impact on LGBTI people’s health. As a marginalised group, and compared with heterosexual peers, LGBTI people experience higher levels of depression, suicide and substance abuse, and are at higher risk for sexually transmitted diseases, including HIV.[2] Because of mistrust in the health system, LGBTI people are less likely to utilise health promotion services, e.g. gynaecological cancer screenings, and are therefore at higher risk for non-communicable diseases.[3] Current SA health policies recognise that transgender people, as well as men who have sex with men, are particularly vulnerable populations.[4] Nevertheless, LGBTI people continually experience discrimination, harassment, and even denial of care by healthcare professionals.[5,6] In countries where legislation penalises homosexuality or homosexual behaviour, LGBTI people may even risk arrest when seeking healthcare. Homophobia continues to be a

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problem in medicine worldwide,[7] and it is important to note that it not only decreases the quality of care for LGBTI patients, but also marginalises LGBTI health professionals. The above-mentioned factors make a compelling argument for the need to teach our health professionals about sexual orientation and gender identity, in order to challenge their attitudes and behaviours, and to equip them with knowledge relevant to LGBTI patients.[2] Training in health professions education is a formative experience for future doctors, nurses and allied health professionals. In order to educate non-discriminatory professionals, it is imperative that their experiences include sufficient opportunities to learn about sexual orientation and gender identity, the healthcare needs of LGBTI people, and ways to provide such care in a compassionate and nonjudgmental manner.

Opportunities for teaching about sexual orientation and gender identity

There are many opportunities for teaching about sexual orientation and gender identity in health professions curricula (Table 1). Among these are first and foremost patient-provider interaction training, but also clinical subjects and contact with health professionals in the field. These professionals can model appropriate care and interest in LGBTI patients, mentor LGBTI students, and conduct research on LGBTI health-related issues. Sexual orientation and gender identity cannot and should not be taught in one specific course, but rather be spiralled through the curriculum to enable students to challenge their own attitudes, and learn about specific LGBTI health issues and the psychosocial well-being of LGBTI people. Courses that endeavour to develop students’ skills in patient-provider interactions are a key opportunity to challenge students’ attitudes and equip them with knowledge to care for LGBTI patients. Aspects of sexual orientation and gender identity should be included when discussing professional behaviour with students, with an emphasis on the ethical

Forum

Table 1. Sexual and gender minority health content in health professions courses Course

Potential LGBTI content

Educational outcomes

Patient-provider interaction training

Discuss professional behaviour and non-judgmental care with regard to sexual orientation and gender identity Address students’ attitudes towards non-heteronormative identities Include LGBTI patients, or patients with same-sex partners in case studies and patient-provider communication exercises History-taking: Teach gender-neutral language (‘partner’ instead of ‘wife/husband’, etc.) Taking sexual histories: Include information about sexual orientation, gender identity and non-heteronormative sexual practices

Awareness of sexual and gender minority identities, heteronormativity, trans- and homophobia as impacting on access to healthcare Recognition of professional standards and conduct of care with regard to sexual and gender minorities Ability to provide culturally competent, non-judgmental care to sexual and gender minority patients

Human biology and development

Discuss sexual orientation and gender identity as part of physiological psychosocial development

Awareness of sexual and gender minority identities Understanding of development and influences on sexual orientation and gender identity

Public health and primary healthcare

Use rights-based frameworks to address sexual orientation and gender identity with regard to: • Access to healthcare • Social determinants of health • Health disparities

Understanding of sexual orientation and gender identity as social determinants of health Ability to assess the social context and health risk factors of sexual and gender minority patients Knowledge of health disparities and the impact of discrimination and social exclusion

Paediatrics

Discuss gender behaviour and gender norms Discuss the difference between sexual orientation and gender identity in sexual development case studies Discuss the impact of homophobia, family and peer pressure on adolescent mental health

Understanding of development and influences on sexual orientation and gender identity Ability to differentiate between biological sex and socially constructed gender, and assess sociocultural impact of the latter Understanding of the impact of discrimination and social exclusion on the health of teenage sexual and gender minority patients Ability to provide clinically competent care to young sexual and gender minority patients

Obstetrics and gynaecology

Discuss lesbian health concerns, such as: • Higher cancer risks (than heterosexual population) • Little uptake of preventative services, including cancer screenings • Higher risks of sexual violence, and subsequent HIV/ STI risks Discuss health prevention needs of transgender men

Knowledge about specific health concerns for lesbian and bisexual women Ability to provide clinically competent care to sexual and gender minority patients

Psychiatry

Discuss the historical pathologisation of LGBTI identities and impact thereof Address the psychological impact of social and internalised homophobia Discuss mental health risks of sexual and gender minority patients Discuss sexual and gender minority patients’ experience of violence and health consequences

Understanding of historical context and resulting barriers to care for sexual and gender minority patients Ability to provide clinically competent care to sexual and gender minority patients

Urology

Discuss health prevention needs of gay men and transgender women

Ability to provide clinically competent care to sexual and gender minority patients

Infectious diseases

Include epidemiological information about HIV prevalence among men who have sex with men Discuss adequate prevention methods for people engaging in non-heteronormative sex

Ability to provide clinically competent care to sexual and gender minority patients

STI = sexually transmitted infection.

obligation to provide care without judgment. Courses that address diversity offer a chance to talk about difference based on sexual orientation and gender identity. Case studies and student exercises can encourage students to think outside of the heteronormative paradigm, e.g. by including an

LGBTI patient, or a patient’s same-sex partner with whom students need to communicate. When students learn to take patient histories, they can be engaged by conducting a sensitive and thorough sexual history that includes ways to ask about sexual orientation and gender identity. Teaching students

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Forum to frame questions in a non-heteronormative manner will help them to identify their own assumptions and biases about sexual behaviour.[8] Furthermore, they will learn about sexual practices beyond the scope of ‘traditional’ heterosexual behaviour, which will in turn enable them to give adequate information to LGBTI patients. Issues of sexual orientation and gender identity are likely to arise in a number of medical disciplines. The teaching presented in these disciplines should build on the introductory information about sexual orientation and gender identity from the early years. Clinical educators play a key role in reminding students to ask questions about sexuality in a non-heteronormative and non-judgemental way, and can shift passive to active learning by asking students to work on issues of sexual orientation and gender identity within a particular case. It is imperative that discussions around sexual orientation and gender identity refrain from judgemental or moral characterisations, and rather focus on the challenges that LGBTI people encounter in contexts of homophobia and heteronormativity. The following section presents opportunities to teach sexual orientation and gender identity in human biology, public health and primary healthcare, paediatrics, obstetrics/gynaecology, psychiatry and infectious disease. Courses in human biology and human development offer a good opportunity for an introduction to sexual orientation and gender identity. The advantage of these courses is that they reach a large student audience, and put sexual orientation and gender identity in the context of normal psychosexual development. Furthermore, they are usually in the early years of health professions education, and bring LGBTI visibility and attitudinal change to students’ attention from the beginning. Of concern is that the information on sexual orientation and gender identity in these lectures may be dated or inaccurate, and that students will not be able to engage as much with the content in formalised lectures and seminars. Including sociologists/ anthropologists in an interdisciplinary team might be a helpful pedagogical approach. Discussions of social determinants of health, barriers to accessing healthcare, and health disparities, taught in public health and primary healthcare, offer the opportunity to include an analysis based on sexual orientation and gender identity. LGBTI people face significant barriers when accessing care in public health facilities, and often avoid seeking care out of fear of homophobic treatment.[9] A rights-based framework can address sexual orientation and gender identity when discussing non-discriminatory care, and can be reinforced by the Patient Rights Charter[10] and Batho Pele Principles[11] (in SA, or relevant documents in other African countries), and professional codes of conduct. Paediatrics and adolescent medicine can address gender behaviour and gender norms, which are often associated with sexual orientation. Children who present with gender atypical behaviour provide an opportunity to discuss gender identity issues and the distinction between sexual orientation (sexual and emotional attraction) and gender identity (one’s sense of being male or female). This can be deepened when teaching about sexual development and puberty. Discussing the role of parental and peer pressure in conforming to gender norms can contribute to shape an understanding of the experiences of long-standing depression and poor self-esteem frequently expressed by LGBTI youth. Obstetrics/gynaecology, with its focus on women’s health, offers opportunities to teach about lesbian health. Lesbian women seek routine breast and cervical cancer screening less often than heterosexual women,

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might have higher risks for endometrial and ovarian cancer, and their providers underestimate their risk of cervical cancer.[2] In SA, lesbian women are at a high risk of experiencing sexual violence, which places them at higher risk for contracting sexually transmitted diseases, including HIV.[12] These topics can be included to address the current lack of awareness of these issues. Some of the many topics suitable for psychiatry are the history of pathologisation of LGBTI identities and the psychological impact of societal and internalised homophobia as well as LGBTI people’s experiences of violence. These topics can be explored with the help of local LGBTI organisations, who are usually willing to provide testimony of LGBTI experiences for students, and facilitate direct interaction with LGBTI individuals. The HIV prevalence among SA men who have sex with men is estimated to be 13%[13] and the self-reported HIV prevalence among lesbian and bisexual women is 10%.[12] Including this information in infectious disease courses will make students aware that LGBTI people are at high risk, and can teach them about prevention methods that are relevant to LGBTI people.

Challenges to implementation

Health professions education exists in a wider societal and cultural context.[14] Despite overwhelming evidence of precolonial non-heterosexual identities,[15] existing homophobic attitudes are often justified by the argument that homosexuality is ‘un-African’ or ‘violates religious values’. Such deep-seated cultural and religious prejudices are difficult to challenge, and, if situated at faculty level, can impact the manner in which topics are taught. Challenging these attitudes at the faculty level is therefore an important imperative to teaching sexual orientation and gender identity. A directive from professional boards (such as the Health Professions Council of South Africa and the South African Nursing Council) could provide the necessary motivation and guidance to include sexual orientation and gender identity in existing curricula.

Teaching by example

We know that role modelling is an important way in which attitudes are fostered.[16] Lecturers and clinical educators need to become LGBTIaffirming role models for students. To accomplish this, faculty should also be encouraged to learn about sexual orientation and gender identity, e.g. through continuing professional development (CPD) courses, departmental presentations, or journal clubs. Departments that have opportunities to include sexual orientation and gender identity topics can be approached and offered consultation to integrate these issues into their curriculum. LGBTI students study in an institutional environment that is often heteronormative and homophobic,[17] and should be supported by faculty staff. Information about LGBTI support services (e.g. through local LGBTI organisations) can easily be made available to all students. Staff should encourage the creation of an LGBTI student group, and make mentors available to individual students who need assistance with homophobic struggles. This can enable LGBTI students to contribute to conversations with heterosexual students where it is safe for them to do so, and can foster the individual interactions that are most effective in addressing homophobia. In my experience, students are often integral to introducing sexual orientation and gender identity into curricula by demanding to be taught about these topics.

Forum Conclusion

Addressing homophobia and remedying the effects of heteronormativity in health sciences curricula is complex. It requires awareness and attitude shifts from educators, which are prerequisites to introducing teaching about sexual orientation and gender identity to students. The curriculum provides multiple opportunities to incorporate such issues, but these opportunities will need to be framed in larger conversations about social inclusion and exclusion to successfully prepare health professions students to provide quality care to LGBTI people. References 1. Müller A. Teaching lesbian, gay, bisexual and transgender health in a South African medical school: Addressing the gap. BMC Med Educ 2013;13:174. 2. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and gender minority health: What we know and what needs to be done. Am J Pub Health 2008;98(6):989-995. [http://dx.doi.org/10.2105/ AJPH.2007.127811] 3. Aaron DJ, Markovic N, Danielson ME, et al. Behavioral risk factors for disease and preventive health practices among lesbians. Am J Pub Health 2001;91(6):972-975. 4. South African National Department of Health. National Strategic Plan on HIV, STIs and TB, 2012 - 2016. Pretoria: Department of Health; 2012. http://www.doh.gov.za/docs/stratdocs/2012/NSPfull.pdf (accessed 4 November 2012).

5. Lane T, Mogale T, Struthers H, McIntyre J, Kegeles SM. 'They see you as a different thing': The experiences of men who have sex with men with healthcare workers in South African township communities. Sex Transm Infect 2008;84(6):430-433. [http://dx.doi.org/10.1136/sti.2008.031567] 6. Wells H, Polders L. Gay and Lesbian People’s Experience of the Health Care Sector in Gauteng. Research Initiative of the Joint Working Group conducted by OUT LGBTI Well-Being in collaboration with the UNISA Centre for Applied Psychology; 2006. http://www.out.org.za/index.php/library/reports# (accessed 29 January 2015). 7. O’Hanlan K, Robertson P, Cabaj RP, Schatz B, Lock J, Nemrow P. Homophobia as a health hazard: Report of the Gay and Lesbian Medical Association. J Gay Lesbian Med Assoc 1997;1:25-39. 8. Cavanaugh RM. Obtaining a personal and confidential history from adolescents. J Adolesc Health Care 1986;7:118-122. 9. Müller A. Barriers to health care for South African lesbian, gay, bisexual and transgender people. Poster presented at the 9th Public Health Association of South Africa (PHASA) Conference, 24 - 27 September 2013, Cape Town, South Africa. 10. Department of Justice. Patients’ Rights Charter. http://www.justice.gov.za/vc/docs/policy/Patient%20Rights%20 Charter.pdf‎ (accessed 5 May 2014). 11. Department of Health, KwaZulu-Natal. Batho Pele principles. http://www.kznhealth.gov.za/bathopele.htm (accessed 5 May 2014). 12. Sandfort TGM, Baumann LRM, Matebeni Z, Reddy V, Southey-Swartz I. Forced sexual experiences as risk factor for self-reported HIV infection among southern African lesbian and bisexual women. PLoS ONE 2013;8(1):e53552. [http://dx.doi.org/10.1371/journal.pone.0053552] 13. Lane T, Raymond HF, Dladla S, et al. High HIV prevalence among men who have sex with men in Soweto, South Africa: Results from the Soweto Men’s Study. AIDS Behav 2011;15(3):626-634. [http://dx.doi.org/10.1007/s10461-009-9598-y] 14. Müller A, Crawford-Browne S. Challenging medical knowledge at the source: Attempting critical teaching in the health sciences. Agenda: Empowering Women for Gender Equity 2013;27(4):25-34. 15. Epprecht M. Heterosexual Africa? The History of an Idea from the Age of Exploration to the Age of AIDS. Athens, OH: Ohio University Press, 2008. 16. Yesidia MJ. Changes in physicians’ attitudes toward AIDS during residency training: A longitudinal study of medical school graduates. J Health Soc Behav 1996;37:179-191. 17. Rose P. Review of Experiences of the Institutional Culture of the Medical Faculty, University of Cape Town. UCT: UCT Students’ Representative Council, 1995.

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Short Report An ethical dilemma: A case of student training, intermittent service and impact on service delivery P Govender, BOT, MOT, CAMAG Discipline of Occupational Therapy, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: P Govender (née Naidoo) (naidoopg@ukzn.ac.za)

One of the fundamental precepts in the training of students in a clinical discipline involves appropriate placement and supervision in order for learning outcomes to be achieved. As an academic/clinical educator, one is at times faced with dilemmas in student placement that challenge one’s personal and professional ethics. This paper highlights one case example that describes student training and the impact on service delivery. Afr J Health Professions Educ 2015;7(1):8-9. DOI:10.7196/AJHPE.405

Training within clinical disciplines is often challenging. In this paper, the author seeks to critically reflect on and evaluate the principle of justice in student training using vignettes to describe dilemmas that surfaced during the clinical placement of students. Fieldwork placement is mandatory in most clinical training programmes. In an attempt to facilitate learning through integration of theory and praxis, one is faced with the challenge of creating these ‘real life’ situations for students in which opportunities are provided for application of knowledge and skills learnt in the lecture room. It is postulated that certain factors are essential for determining a successful learning experience, viz. a well-planned placement, with sufficient time for the clinical educator to meet individual students regularly throughout the placement and for sufficient clients to be available for each student. Given the constraints within institutions in terms of human resources, availability to accommodate students, client turnovers, etc., certain training programmes may lean towards repeatedly using a particular facility to provide the required fieldwork experience. An example below is described to highlight some of the challenges in such a situation.

A case example

While transformation within health science faculties is progressing in South Africa (SA), teaching has shifted from central hospitals to secondary and district hospitals, community health centres and rural areas.[1] In this example, a chronic-care facility has been re-used as a venue for training of occupational therapy students (in a 4-year undergraduate degree programme). The facility is a specialised hospital with 175 beds, providing services to chronically ill clients in need of nursing care. Approximately 10 - 15 students are placed in each rotation, which may very well be viewed as ‘exploitation’ of the facility for training purposes. After review of events that occurred in this facility, the author was bound to pose the question: At what cost to the clients are students provided with these necessary periods of knowledge and skill development? Table 1 lists vignettes of three patients’ experiences. The examples are quoted from anecdotal evidence, i.e. informal discussions and observations within this facility.

Reflections and discussion

As an academic/clinical educator and congruently as an observer within this context, I noted the following as concerns:

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• The issue and concern over sustainability of services, which raises the question of whether it is ethical to provide a standard of care or intervention that differs from the normal routine services provided in such settings. The contravention of common-law duty of continuation of intervention is raised, as seen in Thabo’s case. • Issues around identification of clients for rehabilitation intervention and perceived incidental or consequential exclusion of others, as in Mary’s case. • Clients receiving intermittent services appeared to be disadvantaged by this prevailing system, as described in Alan’s case. These sporadic services raise the question of whether placement of students is disadvantageous to an under-resourced facility. The ethical dilemmas above are commonly found in the provision of health services. Distributive justice[2] (how to dispense or allocate resources); nonmaleficence[3] (the obligation to avoid doing harm directly or indirectly); and paternalism[2] (making decisions for others in what is considered to be their best interests) are issues that are often raised. Consequently a number of occupational injustices[4] were identified, viz. occupational deprivation[4] (when persons cannot engage in occupations that are necessary and meaningful to them because of factors outside their control) as in Mary’s case; occupational alienation[4] (when people experience a prolonged disconnectedness, emptiness, and/or sense of meaninglessness) as in Alan’s case, and occupational imbalance[4] (when some people are over-occupied and others are under-occupied).

Distributive justice: Severe limitation of resource personnel and need for services When ethically arguing for equal access to healthcare for all, the principle of justice and its derivative, distributive justice, is essential. Under section 27 of the SA Constitution,[5] access to healthcare is a recognised right, and in order to achieve success in the provision of health services, there is a need for human rights and ethicolegal principles to be adhered to as monitors of this process. The onus is on the state and therefore staff employed by the state to ensure that steps are taken to realise these rights. However, the provision of the rights depends on whether resources are available. Reid and Cakwe[1] highlighted human resource challenges faced by health sciences faculties in SA. Lack of resources has terminated blocks which had

Short Report

Table 1. Vignettes Vignette 1 Thabo* is a 34-year-old African male, admitted to the facility 3 years ago from a Respite Unit. Diagnosed with stage three, symptomatic retroviral disease, with a CD4 count of 180. He is currently on highly active antiretroviral therapy. He suffered a bilateral cerebrovascular accident 5 months ago and has comorbidities of hepatitis B and encephalomyelitis. Thabo was referred to a third-year student with a focus on therapeutic intervention (rehabilitation). Rehabilitation was clientcentred towards achieving goals aimed at improving Thabo’s quality of life at this stage of care. He responded well to interventions, making gains in his overall motivation, endurance and ability to execute personal management tasks with assistive devices and adaptations. Later that year, he was referred to a secondyear student with a focus on assessment. This process was used as a reassessment of the gains Thabo had made in therapy; however, there were no sustained therapeutic interventions. In the period between these two rotations of students Thabo did not receive any rehabilitation (approximately 3 - 4 months). Vignette 2 Mary* is a 68-year-old Afrikaans-speaking lady who has been residing in the facility for 15 years because of the degenerative nature of her condition (multiple sclerosis). She has symptoms related to loss of sensitivity, general muscular weakness, spasms, incoordination and chronic pain. She is bowel and bladder incontinent and has an unstable mood. She is in a ward with 15 other clients, 10 of whom were engaged in rehabilitation with students. Mary would often verbalise to the students the need to be part of the programme; however, she had not been identified as requiring intervention by the resident rehabilitation therapists. She would often be seen lingering outside therapy areas, and at times in emotional outbursts, swearing profanities at her fellow in-patients who received interventions, indicative of the apparent preference for some clients over others. Vignette 3 Alan,* a 48-year-old Indian male, was diagnosed with a severe traumatic brain injury and C4 complete spinal injury following a hijacking and assault incident. He was admitted to the unit from a rehabilitation setting. He had undergone 8 months of rehabilitation prior to admission. He was allocated to a student in the first rotation in the year and benefitted from individual and group rehabilitation. The students left by mid-year and a new group of students returned 2 months later. During this time, Alan received minimal intervention. When approached to consent to treatment by another student, Alan refused, indicating his refusal was due to non-sustainability of services. *Names have been changed to maintain confidentiality.

previously involved students in community-based projects. This burden has at times been reduced through university and government collaboration. Notwithstanding this, should students then be placed in under-resourced settings given that the general public suffers from the consequence of any decision pertaining to resource distribution and therefore access to healthcare?[2]

Autonomy, beneficence and non-maleficence[4]

The notion of autonomy accepts that a mentally/legally competent client has the capacity to understand, reflect, reason and make an informed decision. In the context of rehabilitation services, this would imply that a mentally/ legally competent individual would be able to make an independent decision on whether or not to receive services. Therapists, on the other hand, are obliged, by virtue of their registration with the Health Professions Council of South Africa, to allocate services primarily on the basis of need. The reality in this setting is that clients are screened, based on their individual needs, and the issue of the client’s willingness to receive these services is raised (autonomy), despite informed consent. It could be argued that provision of services, albeit intermittently, benefits the client. In many rural sites where there are few therapists, students provide a service that would otherwise not have existed.[2] In this case the placement of students could be seen as an act of beneficence.[4] Students prepare detailed handovers with recommendations for continued intervention when they leave. Alan’s experience however demonstrates that clients could feel a sense of abandonment, loneliness and experience negative emotions. This may be a violation of the principle of non-maleficence. This ‘harm’, though not envisaged, needs to be considered at both the referral and handover stages as the service provided is not acting in the best interest of the client (beneficence). According to the Patient’s Rights Charter to

which all practitioners ascribe, no client may be abandoned by a healthcare practitioner, who initially took on the responsibility for the client’s health.[1] Clients are therefore assured of continuity of care.

Conclusion

Training of students within natural clinical environments other than lecture rooms appears to succeed only when specific supports and accommodations are provided to both students and the recipients of the service. While an opportunity for optimal learning, these situations often raise issues of ethical and moral responsibilities that tug at one’s own professional intentions. In the effort to reach outcomes as required by an educational curriculum, the goal of ensuring optimal healthcare to clients remains a paramount professional ethical responsibility. This report was intended to highlight just a few ethical dilemmas that surfaced in one setting. The author remains challenged in ensuring that there is balance between what students can contribute, the demands teaching places on the system for support, and carefully managing ethical principles while ensuring sustainability of these educational initiatives. Acknowledgement. The author would like to acknowledge Mrs N Motala for her insights into the bioethics and health law.

References 1. Reid SJ, Cakwe M. The contribution of South African curricula to prepare health professionals for working in rural or under-served areas in South Africa: A peer review evaluation. S Afr Med J 2011;101:34-38. 2. Dhai A, McQuoid-Mason D. Bioethics, Human Rights and Health Law. Principles and Practice. Cape Town: Juta, 2011. 3. Gelling L. Ethical principles in healthcare research. Nursing Standard 1999;13(36):39-42. 4. Duncan M, Watson R. Transformation through occupation: Towards a prototype. In: Watson R, Swartz L, eds. Transformation Through Occupation. London: Whurr Publishers, 2004:301-318. 5. Constitution of the Republic of South Africa. Act 108 of 1996. Butterworth’s Statutes of South Africa, February 2007. http://www.gov.za/sites/www.gov.za/files/images/a108-96.pdf (accessed 16 April 2015).

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Research Developing an outcomes-based charter to direct teaching and assessment of medical professionalism R Delport,1 MSc, MEd, PhD; C Krüger,2 MB BCh, MMed (Psych), MD, FCPsych (SA); M van Rooyen,3 MB ChB, MMed (FamMed); G Pickworth,4 DPhil (Psych) 1

Skills Laboratory, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Psychiatry, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Family Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa

Department for Education Innovation, University of Pretoria, South Africa

Corresponding author: R Delport (rhena.delport@up.ac.za)

Background. Components of professionalism in undergraduate medical studies at the University of Pretoria (UP) were previously defined as nine ‘Golden Threads’. Although specific outcomes were formulated for the threads, the need for more explicit professional standards became increasingly evident. The restructuring of the health system in South Africa contributed to the need for more explicit standards. The Charter for Medical Professionalism was developed during 2006 - 2008 as a reference document within the local context to serve as a standard for professionalism in the medical curriculum. Another aim was to guide academics in medical studies to act as good role models of professional behaviour. Objective. To document the development of the Charter for Medical Professionalism and to evaluate lecturer and student perceptions on the formulation of the Charter to make appropriate changes and increase acceptance. Methods. The project took the form of action research, and a working group comprising academics from UP’s Faculty of Health Sciences developed the Charter from relevant source documents, employing thematic and content analysis and recursive abstraction. An online survey was conducted to assess lecturer and student acceptance of the Charter. Results. The outcomes-based approach was perceived as acceptable and appears to broaden the scope of assessment of professionalism. Conclusion. Inclusion of outcomes proposed by other work groups relating to research, practice management, teaching, mentoring and leadership roles of the medical doctor may be considered in future. Afr J Health Professions Educ 2015;7(1):10-15. DOI:10.7196/AJHPE.223

Background

The word ‘professions’, derived from the Latin professio, refers to a public declaration of a belief, a faith or an opinion and implies that members of professions will act in certain ways and strictly adhere to a well-defined code of conduct.[1] Professionalism is an important aspect of any high-level occupation; for medical doctors it is an important component of their contract with society.[2] There must be a clear definition of professionalism set out in a code of conduct and accepted by society, members of faculty of medical schools and their students. It should lend itself to change, as professionalism is dynamic, evolves and is multidimensional.[3] It is important to ensure that medical graduates know their code of conduct and understand what is implied by ‘professionalism’ in a work-related context. This is especially important in South Africa (SA)’s rainbow nation’, where a number of threats, including restructuring of the healthcare system, fiscal constraints and conflicts of interest, may erode medical professionalism. The Physician’s Charter for the new millennium[4] is a representation of global opinion on the principles and commitments that pertain to medical professionalism. Desirable professional attributes for medical staff include being a reflective practitioner, responding to social needs, evincing core humanistic values, being accountable, and committing to scholarship and excellence.[5-7] From an identified and agreed-on definition of ‘professionalism’, clear outcomes can be developed and its components become evident through corresponding behaviour. Strong support exists for professionalism to be considered as an explicit learning outcome, a skill set or a competency.[8-11]

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The School of Medicine, University of Pretoria (UP), SA, has employed a number of strategies to promote professionalism, i.e. a University of Pretoria Pledge for Medical Students has been developed and since 1996 it has been customary for final-year medical students to make their pledge at a special ceremony. It is similar to the Declaration of Geneva (2006) but, in addition, students pledge to remain competent practitioners through lifelong learning.[12] Furthermore, in the course of restructuring the undergraduate medical curriculum at UP (from 1997 onwards), a number of ‘Golden Threads’ were included in the curriculum, building progressively on what had been learnt in previous years.[13] These Golden Threads embody important non-physical, humanitarian knowledge, attitudes and professional skills that medical students should have at the end of their 6-year course. Several of these threads – in particular those related to interpersonal skills, professional attitudes, teamwork and ethics – contributed to the development of what came to be called ‘soft skills’.[14,15] The Soft Skills project explored and described undergraduate medical students’ experiences of and viewpoints on soft skills and soft-skills development as part of their professional socialisation as doctors during the 6-year medical education programme.[14,15] Students appeared to be more aware of their development of these soft skills within the new problem-orientated UP medical curriculum than students in the traditional curriculum.[14,15] The concept of a local charter for professionalism developed in the course of formal and informal feedback during 2006 - 2007 from lecturers and medical students. It was clear that all professional standards needed to be defined more clearly within the medical curriculum. For example,

Research from their assessment of medical students’ assignments on professionalism over 5 years of study, Du Preez et al.[13] concluded that such professional standards could be formulated in a charter that stated the principles and commitments relevant to UP and to which all medical professionals should aspire. Appropriate assessment of students’ professionalism, defined by the outcomes in the Charter, would be of vital importance, as assessment reportedly drives learning.[16] Assessment strategies purportedly not only raise awareness among students and faculty members of the core values of professionalism, but also demonstrate the importance of the development of these attributes to the institution.[5,6,17] Therefore, continuous and diagnostic assessment would aid the early detection of unprofessional conduct and lead to timely remediation. From a previous survey it became evident that the Charter should have a distinct local character, as the Physician’s Charter was not perceived as totally acceptable within the SA context by 76% of fifth-year medical students at UP.[11] A subsequent cohort of fifth-year students was required to define professionalism, and described features of professionalism that could possibly be assessed.[18] A qualitative design was employed in this second study to explore students’ perceptions. Attributes used to describe professionalism were grouped under four main domains: attitude and personal conduct; teamwork; patient care; and professional competence. Although similarities with the Physician’s Charter were observed, most students expressed the opinion that the humanistic attributes of professional behaviour, such as empathy, good interpersonal relationships, integrity, respect, maturity and teamwork, were not obviously represented in the Physician’s Charter. Van Rooyen and Treadwell[18] concluded that a locally acceptable charter should be developed for the School of Medicine, UP. It was envisaged that the Charter should reflect the essence of the existing Golden Threads, the guidelines set by the Health Professions Council of South Africa (HPCSA) for professional conduct (HPCSA Professional Guidelines)[19] and UP’s Pledge for Medical Students. Although other bodies were also in the process of defining outcomes for professionalism, e.g. the Association of American Medical Colleges,[20] UK General Medical Council (GMC),[21] Scottish Deans Medical Curriculum Group,[22] and Royal College of Physicians and Surgeons of Canada,[23] not all publications resulting from these international projects were consulted for the formulation of the charter within the UP context. To summarise, the development of the UP Charter for Medical Professionalism was deemed necessary, as a need existed to explicitly define locally relevant standards of professionalism. Defining specific outcomes and assessment criteria relating to medical professionalism would lend consistency to the teaching and assessment of professionalism throughout the medical curriculum and aid in the early detection and remediation of unprofessional conduct. Furthermore, professional development of medical staff would result from their being informed about what was expected of a medical professionalism role model.

Methods

The development of the Charter was conducted as an action research project. Qualitative data were generated from the sources listed below, using thematic and content analysis and recursive abstraction. A representative working group was comprised from the School of Medicine, UP, and included a health sciences education advisor, family physician-lecturer, Department of Psychiatry lecturer, and the Procedural Skills Unit head. The project was conducted from November 2006 to November 2008.

The sources used for the development of the Charter were: • The University of Pretoria Pledge for Medical Students • The Golden Threads outcomes[13] • The HPCSA Professional Guidelines[19] • Medical professionalism in the new millennium: A Physician’s Charter (participants in the Medical Professionalism Project 2002)[4] • Good Medical Practice, GMC.[21] All lecturers from the School of Medicine were invited via corporate email to participate in the study. A survey was conducted to source anonymous feedback on the Charter with the use of an online survey tool, Survey Monkey (http://www.surveymonkey.com). Following incorporation of comments from lecturers, students were invited to participate anonymously in the survey via a pop-up message and link on the university’s learning management system. Respondents had to select one of the following options: agree/reject/reword for the competencies, values and attributes within the domains of professionalism, and for the descriptors of how the competencies may become evident. Consensus was reached within the working group on whether the student comments were too poorly worded for consideration or inappropriate and which changes should be made to the Charter. The revised Charter was then presented to lecturers at undergraduate teaching committee meetings, strategic meetings of the School of Medicine, and induction programmes for newly appointed lecturers. No further proposals were made on invitation to improve the Charter, suggesting general acceptance by faculty. Ethical approval for the study ‘Teaching/learning, assessment and monitoring of medical students’ professional conduct based on a Charter for professionalism’ was granted by the Ethics Committee of the Faculty of Health Sciences (No. 63/2007). Consent was implied by anonymous participation.

Results

Complete responses were received from 52 lecturers in the School of Medicine, 6 of whom were full professors, 9 associate professors, 20 senior lecturers, and 17 lecturers. The student response rate was 15.3%, after exclusion of incomprehensible, incomplete or obviously ridiculous responses. The number of respondents per year group 1 - 6 were 83, 21, 42, 15, 6 and 17, respectively. High levels of agreement in the selection and wording of items were observed in the responses of lecturers and students. The highest percentage for ‘reject’ (7.6%) was observed to relate to the following professional competence: ‘As a medical practitioner or student I am required to demonstrate knowledge and understanding of the principles of managed health care and health care systems in South Africa with special reference to the differences between the public and private sector’. The highest percentage for rewording for any given item was 4.5%. This competency was formulated as follows: ‘As a medical practitioner or student I am required to demonstrate a relevant epidemiological approach’. Table 1 presents all comments and suggestions made within the three domains of professionalism in relation to any of the listed requirements and how they become evident. Table 2 lists the two domains with three separate statements in which relevant comments were made that were suggestive of a poor correlation between the proposed professionalism outcomes and the reality of the workplace. Only 2% of respondents suggested that a descriptor of an outcome be reworded. The revised Charter for Medical Professionalism is presented in Table 3, highlighting what lecturers and students regard as locally relevant standards for medical professionalism.

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Research

Table 1. Specific feedback from student respondents about the three domains of professionalism Domain

Original wording of item

Comment/suggested change

Professional competence

Problem-solving and critical thinking skills are evident when I: • Formulate a management plan after negotiation with the patient/parent/guardian

Problem-solving and critical thinking skills are evident when I: • Formulate a management plan before negotiation (to get an idea of what you plan to do), but am able to adapt it after discussion with patient/parent/guardian (once you have received a better idea of the situation)

Being knowledgeable of and applying relevant laws are evident when I: • Demonstrate personal responsibility and ethical behaviour in my conduct

Addition to the end of the statement: • Realising that one cannot be taught to be ethical and responsible in medical school but must do so in a personal capacity first

• Demonstrate a commitment to improving my knowledge and skills on a continuous basis

• Demonstrate a commitment to improving knowledge and skills where possible

Being knowledgeable of and understanding the principles of managed healthcare and healthcare systems in SA are evident when I: • Apply the principles of managed healthcare, including the principles of fair distribution of healthcare resources, social justice, and access to healthcare for all

I feel that this decision is usually not made by the doctor – it is made by the management running the hospital, and lack of resources to adequately treat patients is a common complaint in many places. This is not usually because of a lack of money, but rather bad management

Ethical values require me to: • Strive to ensure the well-being of all members of society

Ethical values require me to: • Strive to ensure the well-being of all members of society who seek my professional assistance

Acknowledging patient autonomy and empowering patients to make informed decisions are evident when I: • Negotiate a treatment plan with patients

Acknowledging patient autonomy and empowering patients to make informed decisions are evident when I: • Negotiate a treatment plan with patients that best meets both myself, the patients’ and their relatives’ needs

Acknowledging people’s human rights is evident when I: • Respect a patient’s rights and needs

Acknowledging people’s human rights is evident when I: • Respect a patient’s rights and needs as required from me by law and unspoken guidelines

Acknowledging patient autonomy and empowering patients to make informed decisions are evident when I: • Respect their concerns and choices

Unless their choices stand to harm others, especially in the cases of adults making decisions for children

Upholding and maintaining professional behaviour and relationships are evident when I: • Show maturity by a willingness to learn from others, accept constructive criticism, and acknowledge my errors and limitations

I will accept criticism only if it is fully informed and takes availability of hospital resources into account

Ethical values

Personal attributes

… but not stand for unfair and unjust treatment based on my level of education or my race

Table 2. Specific feedback from student respondents suggestive of discordance between the proposed professionalism outcomes and workplace reality Domain

Original wording of item

Comment/suggested change

Professional competence

Being knowledgeable of and understanding the principles of managed healthcare and healthcare systems in South Africa are evident when I: • Apply the principles of managed healthcare, including the principles of fair distribution of healthcare resources, social justice, and access to healthcare for all

Personal attributes

Upholding and maintaining professional behaviour and professional relationships are evident when I: • Show maturity by a willingness to learn from others, accept constructive criticism, and acknowledge my errors and limitations

I will accept criticism only if it is fully informed criticism and if it takes availability of hospital resources into account

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… but not stand for unfair and unjust treatment based on my level of education or my race

Research

Table 3. The Charter for Medical Professionalism: University of Pretoria • This charter guides the professional practice of medical students and practitioners. Both students and practitioners are required to commit themselves to: being informed of their professional responsibilities; a desire to maintain professional behaviour; and maintaining high standards of medical practice • Students and practitioners should demonstrate (i) professional competence; (ii) adherence to ethical values; and (iii) the personal attributes that are associated with professionalism • This charter shows what is expected of students and practitioners in terms of all three of these components of professionalism and also sets out how professionalism is made evident in conduct 1. Professional competence As a medical practitioner or student I am required to: • Demonstrate problem-solving and critical thinking skills • Keep good clinical records • Demonstrate a relevant epidemiological approach • Be knowledgeable and apply relevant laws with special reference to: • Human rights • Relationships (collegial, patient and personal) • Unlawful conduct • Patient procedures (e.g. involuntary admission, etc.) • Demonstrate knowledge and understanding of the principles of managed healthcare and healthcare systems in South Africa, with special reference to the differences between the public and private sectors • Demonstrate a commitment to improving my knowledge and skills on a continuous basis Making these skills and qualities evident • Problem-solving and critical thinking skills are evident when I: • Apply appropriate knowledge (anatomy, physiology, pathology, ethics, etc.) and skills (interpersonal, communication, physical skills, etc.) in the clinical assessment and treatment of patients • Display an evidence-based approach while considering the availability of resources • Formulate a management plan after negotiation with the patient/parent/guardian • Accommodate in myself a degree of uncertainty in clinical decision-making and possible differences of opinion with others • Keeping good clinical records is evident when I: • Record information on the patient and matters relating to patient management in the appropriate format and regularly update this information • Demonstrating a relevant epidemiological approach is evident when I: • Determine the extent of the healthcare problem • Plan and implement interventions using existing resources • Apply appropriate methodology • Being knowledgeable of and applying relevant laws are evident when I: • Demonstrate knowledge of the South African Constitution and relevant laws in my clinical practice • Demonstrate personal responsibility and ethical behaviour in my conduct • Being knowledgeable of and understanding the principles of managed healthcare and healthcare systems in South Africa are evident when I: • Apply the principles of managed healthcare, including the principles of fair distribution of healthcare resources, social justice, and access to healthcare for all • A commitment to continually improving my knowledge and skills for the improvement of my professional competence is evident when I: • Practise evidence-based medicine • Inform my practice with up-to-date information and research • Engage in continuing professional development 2. Ethical values Ethical values require me to: • Demonstrate an appropriate ethical approach to dilemmas in clinical practice and research • Acknowledge people’s human rights • Acknowledge patient autonomy and empower patients to make informed decisions • Uphold honesty as a primary concern • Strive to ensure the well-being of all members of society Continued ...

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Research

Table 3. (continued) The Charter for Medical Professionalism: University of Pretoria Making these values evident • An appropriate ethical approach to clinical and research ethical dilemmas is evident when I: • Identify ethical dilemmas in clinical practice and research • Am accountable in my responses to these dilemmas • Acknowledging people’s human rights is evident when I: • Respect a patient’s rights and needs • Treat people in a fair and just manner • Acknowledging patient autonomy and empowering patients to make informed decisions are evident when I: • Inform patients correctly of their treatment options • Respect their concerns and choices • Negotiate a treatment plan with patients • Upholding honesty as a primary concern is evident when I: • Demonstrate honesty in all my communications and dealings with patients and base all my dealings with patients on integrity • Striving to ensure the well-being of all members of society is evident when I: • Manage available resources responsibly 3. Personal attributes The personal attributes of a medical student or doctor require me to: • Uphold and maintain professional behaviour and professional relationships Making these attributes evident • Upholding and maintaining professional behaviour and professional relationships are evident when I: • Demonstrate desirable personal attributes (such as compassion, empathy, honesty, tolerance, integrity, responsibility, trustworthiness, confidentiality, beneficence, respect for the primacy of the patient, transparency in decisions) in my relationships with patients • Show respect in my demeanour, grooming, adherence to the appropriate dress code, punctuality and attendance • Show maturity by a willingness to learn from others, accept constructive criticism, and acknowledge my errors and limitations • Am able to handle conflict and make appropriate decisions and cope in a crisis • Have good communication and interpersonal skills, such as knowing how to greet patients appropriately and listening well • Show the ability to work in a team through delegating and making referrals appropriately, sharing with colleagues, valuing the input of all team members and recognising all contributions of the team.

Discussion

The Charter for Professionalism of the School of Medicine, UP, was developed to promote a common understanding of how professionalism may become evident, thus heightening student (and lecturer) awareness of professionalism and assuring consistency in the teaching and assessment of professionalism in medicine. To assure ‘buy-in’ from the School of Medicine, the Charter was specifically developed to accommodate the previously defined Golden Threads. Other sources – as listed under Methods – were included in the research process, and feedback from faculty and students was sourced in a local survey. Generally, the survey responses supported the current form of the UP Charter. Although the response rate of the students was relatively low, all years of study were represented. Students are continually invited to comment on the Charter as part of their reflection activities. Comments made by students mostly provided evidence of buy-in, as they proposed subtle changes to the wording of specific outcomes. Some of the comments, however, indicated that discordance might exist between the proposed professionalism outcomes and workplace reality, where resources to treat patients adequately are often lacking (Table 1). The assessment of professionalism within the macro-societal domain may become complicated as a result of a dysfunctional system that needs to be accounted for. As proposed in the ‘Assessment of professionalism: Recommendations from the Ottawa 2010 Conference’,[24] future research may be directed towards exploring ‘professionalism assessment in complex clinical workplaces,

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including how individuals adapt to difficult or even dysfunctional health care systems and the gaps that arise between espoused values and actual practice’. The hallmark paper ‘Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world’ proposes that a competencies-based approach within team-based learning be employed and that global learning should be strengthened.[25] The outcomes-based approach of the UP Charter is therefore in agreement with international trends, as it defines measurable or observable competencies, albeit within the SA context. Cross-referencing between outcome frameworks is, however, indicated.[26] Such an endeavour would aid in identifying gaps and promoting a common understanding of professionalism in the workplace, as is evident from the attributes or competencies proposed for the ‘global doctor’ (The Tuning Project (Medicine), 2012).[27] The unique nature of professionalism as described and understood locally within different medical schools and healthcare disciplines should, however, be appreciated and maintained. Agreement between the outcomes defined in UP’s Charter for Medical Professionalism and those defined in The Tuning Project,[27] Tomorrow’s Doctors,[28] The Scottish Doctor,[29] and The American Board of Internal Medicine (ABIM) Foundation,[30] is highly evident. What appears to be lacking in the UP Charter, however, is emphasis on research, practice management, and teaching, mentoring and leadership roles of the doctor. Furthermore, identification of the attributes of the global doctor is

Research commendable and merits contextualisation and inclusion in the UP Charter. In general, the outcomes-based approach appears to broaden the scope of assessment of professionalism beyond observing behavioural attributes. The Charter is regarded as a working document and is intended to serve as a basis for local discourse on professionalism within a global and transdisciplinary context in health sciences.

Conclusion

Defining outcomes for professionalism in medical practice appears to be universally acceptable. This approach evidently makes professionalism more explicit and assessable and also broadens the scope of professionalism by virtue of defining new roles and responsibilities within the individual, interpersonal, and societal/institutional domains. Acknowledgements. The authors would like to acknowledge the valuable contributions of former members of the Charter for Medical Professionalism Work Group: Ina Treadwell, Renata du Preez and Isobel van der Westhuizen. References 1. Merriam-Webster.com 2012. http://www.merriam-webster.com/dictionary/professions (accessed 18 December 2012). 2. Cruess RL, Cruess SR. Expectations and obligations: Professionalism and medicine’s social contract with society. Perspect Biol Med 2008;51(4):579-598. 3. Hafferty FW, Castellani B. The increasing complexities of professionalism. Acad Med 2010; 85:288-301. [http:// dx.doi.org/10.1097/ACM.0b013e3181c85b43] 4. Members of the Medical Professionalism Project: ABIM Foundation, ACPBASIM Foundation, and European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician’s charter. Lancet 2002;359:520-522. [http://dx.doi.org/10.1016/S0140-6736(02)07684-5] 5. Schuwirth L. Professional development in undergraduate medical curricula from an assessment point of view. Med Educ 2002;36(4):312-313. 6. Ten Cate ThJ, De Haes JCJMM. Summative assessment of medical students in the affective domain. Med Teach 2000;22(1):40-43. [http://dx.doi:10.1080/01421590078805] 7. Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612-616. [http:// dx.doi.org/10.1097/00001888-200006000-00010] 8. Frank JR, Danoff D. The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Med Teach 2007;29:642-647. [http://dx.doi.org/10.1080/01421590701746983]

9. Harris P, Snell L, Talbot M, Harden RM. Competency-based medical education: Implications for undergraduate programs. Med Teach 2010;32:646-650. [http://dx.doi.org/10.3109/0142159X.2010.500703] 10. Van Mook WNKA, van Luijk SJ, O’Sullivan H, et al. The concepts of professionalism and professional behaviour: Conflicts in both definition and learning outcomes. Eur J Int Med 2009;20:e85-e89. [http://dx.doi.org/10.1016/j. ejim.2008.10.006] 11. Van Rooyen M. The view of medical students on professionalism in South Africa. SA Family Practice 2004;46(1):28-31. 12. World Medical Association. WMA Declaration of Geneva. Geneva: World Medical Association, 2006. http:// www.wma.net/en/30publications/10policies/g1/index.html (accessed 18 December 2012). 13. Du Preez RR, Pickworth GE, Van Rooyen M. Teaching professionalism: A South African perspective. Med Teach 2007;29:e284-e291. 14. Joubert PM, Krüger C, Bergh A-M, et al. Medical students on the value of role models for developing ‘soft skills’ – ‘That’s the way you do it’. South African Psychiatry Review 2006;9:28-32. [http://repository.up.ac.za/ handle/2263/15029] 15. Bergh A-M, Van Staden CW, Joubert PM, et al. Medical students’ perceptions of their development of ‘soft skills’ – Part II: The development of ‘soft skills’ through ‘guiding and growing’. SA Family Practice 2006;48(8):15-15d. [http://repository.up.ac.za/handle/2263/15024] 16. Epstein RM. Assessment in medical education. N Engl J Med 2007;356(4):387-396. 17. Papadakis MA, Loeser H, Healy K. Early detection and evaluation of professionalism. Deficiencies in medical students: One school’s approach. Acad Med 2001;76(11):1100-1106. 18. Van Rooyen M, Treadwell I. Pretoria medical students’ perspectives on the assessable attributes of professionalism. SA Family Practice 2007;49(4):17. 19. The Health Professions Council of South Africa. Professional Guidelines. http://www0.sun.ac.za/ruralhealth/ ukwandahome/rudasaresources2009/More/ProfessionalGuidelines.pdf (accessed 18 December 2012). 20. Association of American Medical Colleges. Learning objectives for medical student education: Guidelines for medical schools, 1998. http://www.aamc.org/meded/msop/ (accessed 18 December 2012). 21. The UK General Medical Council. Good Medical Practice. http://www.gmc-uk.org/guidance/good_medical_ practice.asp (accessed 18 December 2012). 22. The Scottish Deans Medical Curriculum Group. http://www.scottishdoctor.org/ (accessed 18 December 2012). 23. The Royal College of Physicians and Surgeons of Canada. CANMEDS Competency Framework 2005. http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/the_7_canmeds_roles_e. pdf (accessed 18 December 2012). 24. Hodges BD, Ginsburg S, Cruess R, et al. Assessment of professionalism: Recommendations from the Ottawa 2010 Conference. Med Teach 2011;33(5):354-363. [http://dx.doi.org/10.3109/0142159X.2010.500703 ] 25. 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] 26. Ellaway R, Evans P, McKillop J, et al. Cross-referencing the Scottish doctor and tomorrow’s doctors learning outcome frameworks. Med Teach 2007;29(7):630-635. [http://dx.doi.org/10.1080/01421590701316548] 27. The Tuning Project (Medicine) 2012. Learning outcomes/competences for undergraduate medical education in Europe. http://www.tuning-medicine.com/exec.asp (accessed 18 December 2012). 28. UK General Medical Council. Tomorrow’s Doctors 2009: A draft for consultation. https://gmc.e-consultation. net/econsult/uploads/TD%20Final.pdf (accessed 18 December 2012). 29. The Scottish Doctor, 2011. Learning outcomes for attitudes, ethical understanding and legal responsibilities. http://www.scottishdoctor.org/node3.asp?id=0900000000 (accessed 18 December 2012). 30. The American Board of Internal Medicine (ABIM) Foundation. http://www.abimfoundation.org/Professionalism/ Physician-Charter.aspxian-Charter.aspx (accessed 18 December 2012).

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Research The implementation of the Objective Structured Practical Examination (OSPE) method: Students’ and examiners’ experiences B Olivier, PhD; V Naidoo, MSc Physiotherapy; W Mudzi, PhD; H van Aswegen, PhD; J Potterton, PhD; H Myezwa, PhD; R Roos, PhD; L Godlwana, MSc Physiotherapy; D Maleka, PhD, MPH; S Mtshali, MSc Physiotherapy; V Ntsiea, PhD, MPH; A Stewart, PhD; M Romm, MSc Pain; C Humphries, MSc Physiotherapy; B Watt, BSc Physiotherapy Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Corresponding author: B Olivier (benita.olivier@wits.ac.za)

Background. Traditionally, physiotherapy practical skills have been assessed by a method that relies on the subjective interpretation of competency by the examiner and lacks the formative benefits of assessment. Objective. To describe and compare student performance and satisfaction and examiner satisfaction with regard to the Objective Structured Practical Examination (OSPE) and traditional mark sheets during the practical skills assessment. Method. Students and examiners taking part in the second-year physiotherapy practical skills test were invited to participate by completing a series of questionnaires. Performance of techniques was marked using both the OSPE and traditional mark sheets. Results. Sixty-seven students and nine examiners participated in the study. Students scored an average of 4.6% (SD ±16.4) better when using the traditional mark sheet. Nonetheless, students and examiners expressed a preference for the OSPE mark sheet. Conclusion. The OSPE mark sheet allows for increased objectivity, as the specific micro-skills are clearly listed and appropriately weighted. This resulted in increased satisfaction, but a decrease in marks obtained. By assessing the effect of implementation of the OSPE method on performance and satisfaction, change in the current situation can be monitored. Afr J Health Professions Educ 2015;7(1):16-21. DOI:10.7196/AJHPE.228

OSPE is an abbreviation for Objective Structured Practical Examination. In the literature the terms OSPE and OSCE (Objective Structured Clinical Examination) are sometimes interchanged.[1] For the purpose of this article, the term OSPE will be used, as this method is solely applied in the assessment of practical skills and not in the application of these skills in the clinical setting. The OSPE consists of a circuit of stations that tests a variety of techniques to establish practical competence. It has been researched and shown to be an effective, valid, reliable and defendable assessment method in emergency medical training,[1] nursing,[2,3] physiology[4] and oral surgery.[5] At the University of the Witwatersrand, Johannesburg, South Africa, the OSCE method is currently used in the graduate entry medical programme (medicine) and in the undergraduate nursing programme. The traditional, unstructured method of practical skills assessment has three variables, which have the potential to increase the subjectivity of the method[4,5] and consequently interfere with the assessment of the student. These variables include the student, examiner and technique.[1] The OSPE method is an attempt to control examiner and technique variability. An attempt is also made to standardise the environment and process of the practical skills test.[4] Currently, the students’ peers act as models during a practical skills test, which introduces a certain amount of standardisation as they are free from comorbidities that may complicate the assessment. The structured nature of the OSPE decreases the variability of the examiner, which is especially important as they often have different levels of experience.[5] Second-year students have not yet been exposed to the clinical area and during a practical skills examination, where a peer is used as a model, the outcome or effect on the patient cannot be judged.[6] At second-year level, the focus is on competency in technique rather than effectiveness of

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treatment. Students are still learning the elements needed to execute the skills safely and effectively.[7] This makes it possible to control the practical skills test, including the examiner, technique and environment, to improve objectivity, consistency and fairness to all students. Traditionally, physiotherapy practical skills have been assessed by a method that leaves room for subjective interpretation of competency and at times lacks the formative benefits of assessment. The OSPE method attempts to control for the variability of the examination by providing examiners with a checklist that contains the micro-skills required from the student to be able to effectively complete the practical technique and by providing clear instructions to examiners, students and models. The influence that a change in method will have on student performance is as yet unclear. This study sought to evaluate the effect that a change in method of assessment would have on student performance and level of satisfaction. As such, the objective of this study was to describe and compare students’ and examiners’ perceptions of the OSPE and traditional mark sheet in the assessment of students’ practical skills. A further aim was to compare the examiners’ ratings of students’ performances when using the OSPE mark sheet with those of the traditional mark sheet.

Methods

This was a quantitative, descriptive and comparative study. Ethical clearance was granted by the Human Research Ethics Committee of the University of the Witwatersrand. All second-year physiotherapy students and examiners participating in the practical tests were invited to participate in the study. Informed consent was obtained from the students and examiners. Students and examiners involved in supplementary practical tests were excluded. Student and examiner satisfaction were assessed with self-administered questionnaires. Student and examiner satisfaction questionnaires were developed.[8,9]

Research Content and construct validity and reliability were established. A group of 10 physiotherapists (not participating in the main study) were asked to critique the content of the questionnaires. The group consisted of academics, clinicians and students. Suggestions were incorporated and questionnaires were modified accordingly. A pilot study was performed to establish the time taken to complete the questionnaires and to establish their reliability. Each of the 10 students and the examiners participating in the pilot study were invited to complete the questionnaires twice over a period of five days. The development of the OSPE mark sheets was done according to the following steps:[1] • Second-year students were divided into groups of 10. • Each group was given a technique to break down into micro-skills or steps. • A discussion took place between the groups. • Where necessary, the list of micro-skills was added to or modified, or the sequence of performance changed. • This list was given to the lecturer who weighted each item according to her own perception of importance or difficulty. The weighting of micro-skills was performed by the lecturer and not by the students, as it was felt that experience was needed to judge certain microskills as being more important than others. • Two weeks before each practical test, all examiners involved discussed the technique and weighting of each micro-skill. • During the practical test, each examiner made notes with regard to the original set of microskills for the technique being examined. Possible concerns regarding the specific technique were to be discussed after the examination. • All techniques used during the practical test were re-evaluated and modified where necessary. During each practical test, there were six stations of five minutes each. One technique was examined at each station. Stations 1 - 3 were assessed by one examiner at each station using the traditional mark sheet. Stations 4 - 6 were assessed by two examiners at each station – one examiner used the traditional mark sheet and the other the OSPE mark sheet. The OSPE examiners moved to stations 1 - 3 halfway through the practical test. These two examiners were positioned at separate tables and not allowed to share their experiences during or immediately after the assessment. The behaviour of the examiners and the procedures were standardised at each station (Addendum A). Students were made

aware of the information stated in the instructions to examiners (Addendum A). For each micro-skill, a limited number of ratings was available to improve reliability.[8] A rubric was provided for clarity on the allocation of marks: 0/6=0% (incompetent); 2/6=33% (poor performance); 4/6=66% (satisfactory performance); 6/6=100% (excellent); and 2/4=50% (competent). If there was any discrepancy in the marks given by the traditional compared with the OSPE mark sheet, the higher mark was awarded to the student. This ensured that students were not disadvantaged by participating in this study. Directly after the practical test or examination, all students and examiners were given the first student and examiner satisfaction questionnaires, respectively, to complete. Students and examiners were directed to separate rooms where they completed the questionnaires. Participants were required not to discuss the questions or answers with one another, but merely to give honest answers. Two days after the marks and practical mark sheets were returned to the students, they were asked to complete the second student satisfaction questionnaire, as it was argued that students’ perceptions may change after they received their marks. The same procedures were followed as described above for completing the first post-practical questionnaire. Descriptive statistics were used to analyse the demographic details of the study sample. Student

and examiner satisfaction and student performance were analysed using frequencies and presented in tables as appropriate. Student performance during the practical test using the traditional and OSPE mark sheets was presented using means and standard deviations, while student performance using the two mark sheets was compared using a paired t-test. Performance was compared at stations where a student was examined by using both the OSPE and traditional mark sheets at the same time.

Results

Sixty-seven students took part in the study. The average age was 21.3 years (SD ±2.4). There were 10 (15%) male and 57 (85%) female students in the study sample. Nine examiners participated in the study. Of these, 3 (33%) were male and 6 (66%) were female. The overall student performance when using the OSPE and traditional mark sheets is shown in Table 1. The difference in student marks when using the OSPE and traditional mark sheets (combined) is shown in Table 2. The mean student mark was 4.6% higher when using the traditional mark sheet than with the OSPE mark sheet. The student satisfaction with the practical test (soon after the test but before knowing their marks) is shown in Table 3.

Table 1. The overall student performance when using the OSPE and traditional mark sheets (combined) (N=563)* Marks allocated via:

Mean, %

±SD

±SEM

Correlation

p-value

Traditional mark sheet

64.4

20.4

0.86

0.7

0.000

OSPE mark sheet

59.8

18.8

0.79

SD = standard deviation; SEM = standard error of mean. *Marks allocated to the performance of different techniques were added together.

Table 2. The difference in student marks when using the OSPE and traditional mark sheets (combined) (N=563)* Marks allocated via:

Mean difference, %

±SD

±SEM

95% CI

t-value

p-value

Traditional mark sheet minus OSPE mark sheet

4.6

16.4

0.69

3.3 - 6.7

6.7

0.000

SD = standard deviation; SEM = standard error of mean; CI = confidence interval. *Marks allocated to the performance of different techniques were added together.

Table 3. General student satisfaction with regard to the practical test (N=67)* Item

Agree, n (%)

Disagree, n (%)

The practical test was fair

65 (97)

2 (3)

In general I’m satisfied with the way the practical test was conducted

65 (97)

2 (3)

*Feedback from students directly after the practical tests, before they had access to their marks.

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Research

Table 4. Student views on the use of the two mark sheets (traditional and OSPE) (N=59)* Item

Agree, n (%)

Disagree, n (%)

The OSPE marks I received matched my own perception of my performance

36 (61)

23 (39)

The traditional marks I received matched my own perception of my performance

42 (71)

17 (29)

Mark allocation using the OSPE mark sheet is fair

48 (81)

11 (19)

Mark allocation using the traditional mark sheet is fair

36 (61)

23 (39)

The OSPE mark sheet should be used in the practical examination in future

43 (73)

16 (27)

The traditional mark sheet should be used in the practical examination in future

31 (53)

28 (47)

*Eight students did not complete the second student satisfaction questionnaire as they were absent on the day that the questionnaires were handed out.

The majority of students thought that the practical tests were fair. Those who disagreed on the fairness and general conduct of the practical test indicated that they perceived it as too rushed and were not given enough time ‘to think’. Students’ views on the use of the two mark sheets are shown in Table 4. On average, more students thought that the marks from the traditional mark sheets matched their own perception of their performance than the marks on the OSPE sheet. However, on average more students thought using the OSPE mark sheet was fairer compared with the traditional sheet. The student satisfaction with the two mark sheets after receiving their marks is shown in Table 5. The students were satisfied with both the traditional and OSPE mark sheets after receiving their marks. Some students felt that the traditional mark sheet allowed for better marks to be obtained and that the examiners ‘think more about what you deserve rather than just giving ticks and crosses’. Students who preferred the OSPE mark sheet felt that the specific microskills that were listed made the process much more objective and ‘specific’. The examiners’ views on the use of the traditional mark sheet are shown in Table 6. Both the traditional and OSPE examiners were satisfied with the general conduct of the practical examination. The examiner who indicated dissatisfaction with the way in which the practical test was conducted stated that more time was needed in between students to add up the marks. The examiners’ satisfaction with the two mark sheets is shown in Table 7. More examiners were satisfied with the OSPE mark sheet than the traditional one. The examiner who was dissatisfied with the OSPE mark sheet indicated that the weighting of some of the micro-skills should be adapted to obtain a better reflection of the students’ overall performance.

Discussion

Before this study was conducted, practical tests in the university’s physiotherapy department were done where students’ ability to perform certain skills or techniques was evaluated. However, these practical tests were conducted in a partially unstructured manner, where the technique, examiner and environment were not controlled adequately. The traditional mark sheets left much room for the examiner’s subjective interpretation of components or micro-skills to be assessed and weighting of the former (Addenda B and C). The marks awarded when using the OSPE mark sheet were on average 4.6% lower than when using the traditional mark sheet; however, a relatively good correlation of 0.7 was found between the two types of mark sheets. The difference in marks may be because the OSPE sheet has numerous microskills listed, each with a predetermined weighting. With the traditional

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Table 5. Student satisfaction with the traditional and OSPE mark sheets (N=59)* Total Mark sheet

Satisfied, n (%)

Dissatisfied, n (%)

Traditional

46 (78)

13 (22)

OSPE

48 (81)

11 (19)

*Feedback from students after they received their practical test marks.

Table 6. Examiner satisfaction regarding the general conduct of the practical test (N=9) Total Question

Agree, n (%)

Disagree, n (%)

In general I’m satisfied with the way the practical test was conducted

8 (89)

1 (11)

Table 7. Examiner satisfaction with the traditional and OSPE mark sheets (N=9) Total Mark sheet

Satisfied, n (%)

Dissatisfied, n (%)

Traditional

5 (56)

4 (54)

OSPE

8 (89)

1 (11)

mark sheet it is therefore possible that examiners may not notice if a student omitted a micro-skill, or that it may have been done in an incorrect manner. For example, when a contract relax technique of the knee is the being tested, the student may position the model’s leg incorrectly or may have forgotten to explain the findings to the model. Each of these two micro-skills appear on the OSPE mark sheet and should therefore be assessed in a uniform manner by all examiners. Each micro-skill is allocated a predetermined weighting; therefore, all examiners will subtract the same amount of marks for a skill that is poorly executed or omitted. According to the literature, the OSPE mark sheet gives a more valid presentation of a student’s true ability to perform a technique.[4,9] Traditionally, students did not receive optimal formative benefits when the traditional mark sheet (Addendum B) was used. This lack of benefit may be attributed to the lack of specificity as explained above and the need for extensive writing within the time allocated at each station. The time was not always enough to thoroughly assess the performance of the technique and write in enough detail what the student did correctly and incorrectly.

Research Feedback to the students was therefore often inadequate. Larsen and JeppeJensen[10] found that one of the greatest benefits of the OSPE was immediate feedback. Feedback motivated students and improved their learning. In this study, feedback was given a week after the practical test. By reviewing this delayed time frame, one can improve on formative benefits. In this study, students felt that the practical test was fair and were in general satisfied with the manner in which it had been conducted, even though they did not have access to their marks at that point in time. The abovementioned feedback is highlighted as students’ opinion had not yet been biased by the marks that they received for the practical tests. This finding is supported by Ryan et al.[3] Although student satisfaction could not be compared with that of previous years, the controlled environment and behaviours of examiners may have contributed to the positive attitude of the student. The negative impact of external factors, such as the effect of examiner behaviour on student performance, was emphasised by Larsen and Jeppe-Jensen.[10] They also highlighted the importance of a positive atmosphere. Furthermore, all students were marked by the same examiners, which decreased the variability in marks owing to mark differences. All these factors can contribute to student satisfaction. On average, students felt that the traditional mark sheet reflected their performance better than the OSPE sheet. This may be the result of the marks showing a better performance when marked with the traditional mark sheet. Students were satisfied with both the traditional and OSPE mark sheets. Even though their marks were lower when marked with the OSPE sheet, they did report that they felt the OSPE was fairer and should be used in practical tests in the future. Feedback given in studies done by Menezes et al.,[11] Larsen and Jeppe-Jensen[10] and Abraham et al.[4] confirm that students were in favour of the OSPE. They also found that the OSPE mark sheet was described as fair owing to the increased objectivity, which results from the specific micro-skills being clearly listed and appropriately weighted in each of the OSPE mark sheets. The OSPE also increases the inter-rater reliability when less experienced examiners are involved in marking practical tests, and in cases when examiners are marking stations on content that they have not taught the students.[8] Human resource constraints makes it impossible for examiners to mark only those stations that are testing skills that they taught the students. Chenot et al.[8] found moderate to good reliability when the mark allocation of less experienced examiners was compared with that of more experienced examiners when using the OSPE and stated that training of examiners may improve reliability. Examiners were satisfied with the conduct of the practical examination, regardless of which mark sheet was used. This finding is important as it excludes bias towards the practical tests that may not be related to a specific utilised mark sheet. It may also indicate that the specific guidelines given to examiners (Addendum A) may have contributed to decrease uncertainty with regard to factors such as prompting and time keeping. Improvement of these factors will increase inter-rater reliability.[8] Larsen and Jeppe-Jensen[10] and Qureshi[12] found that examiners perceived the OSPE favourably and as

a good test of clinical relevance. Examiners in this study were satisfied with the OSPE mark sheet, more so than with the traditional one. The process whereby OSPE mark sheets were developed gave students the opportunity to learn, as it contributed to their development. The OSPE mark sheet will be refined in future research, as Chenot et al.[8] found greater reliability between micro-skills where mark allocation is dichotomous. The lower the number of options available, the lower the leeway for interpretation. They furthermore suggested that training of examiners can improve reliability in an OSPE.[8] A traditional and an OSPE examiner were present at only three of the six stations owing to human resource constraints. The best possible solution to this limitation was to move the three OSPE examiners to different stations halfway through the practical test. Participating examiners should preferably remain in their specific stations. Examiners had different levels of experience, including clinical and practical examination experience. Olivier et al.[13] found that there was a high correlation between examiners with a similar number of years of experience. To overcome the different levels of experience[1] all staff underwent a briefing session on behaviour, the practical test process and the mark sheet before the practical test was undertaken.

Conclusion

Practical examinations will always contain an element of subjectivity, but the amount of subjectivity can be limited by using the OSPE mark sheet during practical tests. The clearly operationalised list of items that forms part of the OSPE method of assessment makes it the most objective method available to assess the practical competence of students. Although students and staff were satisfied with the traditional manner in which practical skills were assessed, the satisfaction arising from introducing an evidence-based, educationally sound method of assessment by using the OSPE mark sheet in practical tests is shown. References 1. O’Connor HM, McGraw RC. Clinical skills training: Developing objective assessment instruments. Med Educ 1997;31:359-363. 2. Kurz JM, Mahoney K, Martin-Plank L, et al. Objective structured clinical examination and advanced practice nursing students. J Prof Nurs 2009;25:186-191. [http://dx.doi.org/10.1016/j.profnurs.2009.01.005] 3. Ryan S, Stevenson K, Hassell AB. Assessment of clinical nurse specialists in rheumatology using an OSCE. Musculoskeletal Care 2007;5:119-129. 4. Abraham RR, Raghavendra R, Surekha K, et al. A trial of the objective structured practical examination in physiology at Melaka Manipal Medical College, India. Adv Physiol Educ 2009;33:21-23. [http://dx.doi. org/10.1152/advan.90108.2008] 5. Macluskey M, Hanson C, Kershaw A, et al. Development of a structured clinical operative test (SCOT) in the assessment of practical ability in the oral surgery undergraduate curriculum. Br Dent J 2004;196:225-228. 6. Medley D. Teacher Competency Testing and the Teacher Educator. Ablex: New Jersey, 1984. 7. Miller GA, Galanter E, Pribram KH. Motor Skills and Habits. Harmondsworth: Penguin, 1970. 8. Chenot JF, Simmenroth-Nayda A, Koch A, et al. Can student tutors act as examiners in an objective structured clinical examination? Med Educ 2007;41:1032-1038. 9. Patricio MF, Juliao M, Fareleira F, et al. Is the OSCE a feasible tool to assess competencies in undergraduate medical education? Med Teach 2013;35(6):503-514. [http://dx.doi.org/10.3109/0142159X.2013.774330] 10. Larsen T, Jeppe-Jensen D. The introduction and perception of an OSCE with an element of self- and peerassessment. Eur J Dent Educ 2008;12:2-7. [http://dx.doi.org/10.1111/j.1600-0579.2007.00449] 11. Menezes RG, Nayak VC, Binu VS, et al. Objective structured practical examination (OSPE) in forensic medicine: Students’ point of view. J Forensic Leg Med 2011;18:347-349. [http://dx.doi.org/ 10.1016/j.jflm.2011.06.011] 12. Qureshi NS. Examiners’ perceptions of the objective structured clinical examination in colposcopy. J Obstet Gynaecol 2013;33:188-190. [http://dx.doi.org/10.3109/01443615.2012.737050] 13. Olivier B, Naidoo V, Humphries C, et al. Inter-examiner reliability when using the Objective Structured Practical Examination (OSPE) mark sheet for physiotherapy practical examinations. S Afr J Physiotherapy 2013;Wits Special Edition:21-28.

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Addendum A. Instructions to examiners Reading the question Give the student time to read their question in silence before they start (±30 sec). Greeting and politeness Examiners should greet the students politely. Put the student at ease by having a neutral expression on your face. Prompting students If a student leaves out a step of the technique, you should prompt him/her. However: • You should wait until s/he has completed the whole skill before prompting, in case s/he remembers by her/himself • Only prompt once • S/he will lose at least half the marks for that step Keeping time: 5 minutes per station Guide the candidate in terms of time – one prompt per station when needed. Please send students away the moment the bell rings, even if they have not finished. General information • Students have to talk to the patient/model throughout the exam – explain what they are going to do, their findings, etc. • Whenever the student is doing a procedure which will not be relevant to discuss with the patient/model, the student has to tell the examiner what they are doing while they are doing it. • Make sure that students don’t just talk without doing a technique. It is however important that they talk through the technique so that we don’t miss important steps that may not be so clear just from observing their actions. • Some patients/models help students indirectly, e.g. by positioning themselves correctly. If you notice this please reprimand the model. • Some lecturers wish to use the opportunity to teach students while they are examining them. Please do not do this since it gives students tips for the following stations and it takes up time. Students will receive their mark sheets back and will be able to learn from the feedback. • The student can make an appointment to discuss his/her performance with the examiner at a later stage. • Examiners should write a short report after the prac test/exam on common errors made by students, as well as other problems encountered at their station.

Addendum B. Physiotherapy examination form PHYSIOTHERAPY EXAMINATION FORM NAME: ……………………………………………… DATE: ……………………… QUESTION/PROBLEM:………………………………………………………….………………………………… Possible marks 1. General 1.1 Professional appearance & conduct 1.2 Preparation of patient & equipment (including positioning) 1.3 Interaction with patient (explanation, motivation, physical handling, respect & use of voice.

COMMENTS 2. Technique 2.1 Correct choice 2.2 Demonstration 2.3 Application of technique (appropriate hand position, ROM, use of body weight, depth, sequence etc) 2.4 Effectiveness of technique

COMMENTS 3. Background knowledge and recording

5 TOTAL 50

PERCENTAGE:

…………………………………………..

SIGNATURE:

………………………………………

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Marks awarded

Research

Addendum C. Example of OSPE mark sheet PHYSIOTHERAPY EXAMINATION FORM Name: ______________________________________________ Date: ___________ Question/problem: Demonstrate use of the contract relax technique to improve his knee flexion range of movement 1. General

Professional appearance & conduct

Preparation of area & equipment

Interaction with patient (explanation, motivation, physical handling, respect & use of voice)

Comments 2. Technique

/40

Screening for contra-indications

Positioning of patient â&#x20AC;&#x201C; high sitting or prone

Student places segment at the end point of limitation within the movement pattern

Resistance is then given either to the restricted agonist (direct contraction) or to the antagonist (reciprocal relaxation)

Allow a few degrees of motion to ensure that all the muscles in that group have been recruited

Duration and intensity of contraction should be sufficient to generate a strong contraction (approx 5 sec )

Ask pt. to completely relax after which segment is passively/actively taken into new available ROM

Repeat procedure

Explanation of findings to patient

General impression

Comments: 3. Background knowledge and recording Difference between the Contract Relax and Hold Relax Techniques?

2.5

The contract relax method uses an isotonic contraction while the hold relax uses an isometric contraction Comments /5 TOTAL /50 PERCENTAGE Name of examiner: __________________________ Signature: _____________

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Research Students’ experiences of inter-professional education through International Classification of Functioning-based activities at a community-based rehabilitation centre M Kloppers,1 MOccTher; H E Koornhof,2 MNutr; J Bester,1 MPhil (Higher Education); F Bardien,3 MAud Division of Occupational Therapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

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

2 3

Division of Speech, Language and Hearing Therapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Corresponding author: M Kloppers (maatje@sun.ac.za)

Introduction. The training of healthcare professionals is faced with many challenges. To ultimately strengthen the health system, training has to respond to new health challenges, health science developments and societal needs. The Bishop Lavis Primary Health Care Project was established in 1993 and led to the establishment of the Bishop Lavis Rehabilitation Centre (BLRC). The current inter-professional service delivery at the Centre is based on the World Health Organization’s International Classification of Functioning (ICF) model for holistic client-centred care. The objective of this article is to describe the students’ experiences of inter-professional education (IPE) through ICF-based activities at BLRC. Methods. Data were gathered from a retrospective review of student feedback forms from 2010 to 2012. Content analysis was employed to identify key themes regarding IPE. Results. Inter-professional learning was found to occur spontaneously between the four allied health professions as a result of the ICF model-driven activities at BLRC. Conclusion. Feedback at the end of the students’ clinical placement was open ended and no information was asked specifically about IPE. More than half of the students spontaneously mentioned that learning about working in an inter-professional team as one of the highlights of their placement at BLRC, has prompted the sharing of this information. This article offers a potential framework (ICF) that fosters and supports the IPE philosophy in a clinical setting. Afr J Health Professions Educ 2015;7(1):22-25. DOI:10.7196/AJHPE.289

The education of health professionals needs to respond to new health challenges, health science developments and health needs of society to strengthen the health system. Frenk et al.[1] reported the findings of the Lancet’s Global Independent Commission into the Education of Health Professionals for the 21st century, and stated that the education of health professionals has not kept pace with the major challenges of providing health security to all. Some of the problems mentioned by the Commission include: poor teamwork; narrow technical focus without broader contextual understanding; mismatch of competencies with regard to patient and population needs; episodic encounters rather than continuous care; and predominant hospital orientation at the expense of primary care. The Commission believes that academic institutions are liable for these problems, as curricula are fragmented, outdated and static.[1] The training of healthcare professionals is indeed a challenge and needs to ensure that entry-level professionals are equipped with the necessary skills and competencies to provide the highest standard of care for their clients. In South Africa (SA), the Health Professions Council of South Africa (HPCSA) promotes the health of all South Africans ‘by determining standards of professional education and training and setting and maintaining the highest standards of professional and ethical behaviour for its registered healthcare professionals’.[2] This is achieved by establishing and monitoring the standards of professional education and training of the different healthcare professionals and setting standards for

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professional and ethical conduct of qualified professionals registered with the HPCSA. The different professional bodies each have guidelines that determine the content of the different courses, but the core ethical values and standards for good practice are generic and apply to all healthcare professionals. The core ethical values and standards for good practice are respect for persons, beneficence, non-maleficence, human rights, autonomy, integrity, truthfulness, confidentiality, compassion, tolerance and justice.[3] Training for the healthcare professions has to include a comprehensive approach that addresses the needs of all South Africans, including skills to provide health promotion, health prevention, and curative and rehabilitation services. Healthcare professionals also need to be trained in social and technical skills to work together as a team.[4] Since 1993, the healthcare system in SA has been expanded, transformed and revitalised, and parallel to this there have been major growth and developments in health science, professional education and training.[5] Concurrently, an increased understanding of the value and need to include inter-professional education (IPE) in the training of healthcare students has developed.[1,6] IPE is defined as: ‘When two or more professions learn with, from and about each other to improve collaboration and the quality of care’.[7] IPE can be utilised to prepare healthcare students for effective inter-professional practice, as it enhances their knowledge and understanding of the skills, roles and responsibilities of other healthcare professions and builds an awareness of the value and importance of collaboration and teamwork.

Research Effective inter-professional teamwork is one way to improve healthcare delivery and maximise healthcare outcome.[8] The Bishop Lavis Primary Health Care Project[9] was established in 1993 as a result of a partnership between the Faculty of Medicine and Health Sciences at Stellenbosch University (SU), Western Cape Government health authorities, City of Cape Town and Bishop Lavis community. The initial focus of this project was to assist with the reorientation of the healthcare services and deliver a comprehensive service. From the onset, an inter-professional approach was used involving nurses, family medicine practitioners, a physiotherapist, an occupational therapist, a social worker, a dietician and voluntary community workers. Establishment of community participation was an integral part of the project, where students and staff have worked together with community volunteers and the community health committee with regard to service, research and community development. The Bishop Lavis Rehabilitation Centre (BLRC) was established, which currently delivers an inter-professional service that includes physiotherapy (PT), occupational therapy (OT), speech-language and hearing therapy (SLT), and dietetic (DT) students and community volunteers. A number of successful, sustainable community-based intervention programmes and activities have been established through this partnership. These programmes are needs driven and initiated by BLRC’s inter-professional team in collaboration with the community, and are now independently managed by community members with support from BLRC. Examples of these programmes are the weekly stroke support group and bi-weekly exercise and aerobics group. The latter was established because of a need identified by the BLRC team for physical activity and weight management to enhance the wellness of community members. In partnership with the community, members were trained and helped to establish the aerobics and exercise group, which is now independently managed by a community member. The services rendered at BLRC are based on the World Health Organization (WHO)’s International Classification of Functioning (ICF) model[10] for holistic patient-centred care. The ICF model places the focus of assessment on ‘health’ and ‘functioning’ rather than ‘disability’ and ‘illness’. Based on the ICF model, the three domains of a client’s functioning, i.e. activity, participation and body functioning and structures, are addressed while taking into account the environmental and personal factors also influencing the client’s functioning.[10] Research by Kloppers[11] showed that a significant improvement in clients’ functioning is achieved with this approach. Prevention and promotion activities performed by the BLRC inter-professional team address these contextual factors. The Western Cape Department of Health’s plan for the re-engineering of primary healthcare[12] is currently being developed and focuses on teamwork and reaching clients in their home environments. The core services delivered to the Bishop Lavis community by BLRC already encompass this vision.[11] This article describes how this service allows students to be trained in an inter-professional manner to ensure optimal and holistic client and community rehabilitation. A description of the services rendered at BLRC explains the context in which the training takes place.

Description of BLRC services

In 1993, members of the Faculty of Medicine and Health Sciences, SU, realised the need for a training platform within a community to give students an opportunity to become involved in and be exposed to primary healthcare and planning and delivery of healthcare services to

Table 1. Students trained annually at the Bishop Lavis Rehabilitation Centre Profession

Study year

Dietetics

Fourth (final) year

Occupational therapy

Fourth (final) year

Occupational therapy

Third year

Physiotherapy

Fourth (final) year

Physiotherapy

Third year

Speech-language and hearing therapy

Fourth (final) year

a community, based on the needs of that community.[9,13] The services of BLRC are planned and managed by a full-time SU-appointed occupational therapist and physiotherapist with an inter-professional approach. Services and care facilities in the Centre are shared by all professions, which provides opportunities for informal inter-professional learning. BLRC has developed services to address the health needs of the Bishop Lavis community and training needs of SU students. It started with only occupational therapy and physiotherapy services being delivered at the Centre and dietetic services at the community health centre, with sporadic contact for health promotion. Speech-language and hearing therapy services started intermittently from 1995, owing to the lack of a full-time speech therapist at the Centre. Since 2004, this service has been offered on a fulltime basis during student trimesters. From 2012, dietetic students formed an integral part of the services rendered at the Centre. Approximately 92 students are trained at BLRC annually, with average placement duration of 6 - 7 weeks per student. Table 1 gives a breakdown of the number of students per programme. The number of hours worked per student per week ranges from 20 to 40. The generic aims for students’ involvement at BLRC are as follows: (i) developing an understanding of the role and responsibilities of the different members of the rehabilitation team; (ii) assisting in the rendering of a comprehensive therapy service to the Bishop Lavis community by developing an understanding of the humanity of clients and willingness to take holistic responsibility for clients – broader than the defined professional role of caring; (iii) enabling the development and adoption of ethical values and standards for good practice, i.e. respect for persons, beneficence, non-maleficence, human rights, autonomy, integrity, truthfulness, confidentiality, compassion, tolerance and justice, as prescribed by the HPCSA; (iv) providing the opportunity to gain training in community-based rehabilitation; and (v) providing the opportunity for engaging in inter-professional communication and co-operation. The service rendered at the Centre and in the community by the four disciplines and community volunteers is based on the ICF model, which ensures a holistic approach to client care and community interventions. This is achieved by assessing clients’ and group members’ activity and participation needs and taking into account the environmental and personal factors that could influence performance. Intervention services are planned in a weekly inter-professional team discussion. Disciplines then co-ordinate their input according to the client’s needs to improve, adapt or maintain current functioning so that all involved can lead healthy and fulfilling lifestyles.

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Research The service, and how it lends itself to being inter-professional, is explained as follows: • Management of clients on a one-on-one basis. Students are encouraged to ‘shadow’ other professionals, with the clients allocated to them for management. They conduct joint treatment sessions so that clients receive comprehensive treatment where applicable. If more than one profession is involved in the treatment, the client’s name is added to the board in the student room and the names of the persons from the different professions involved in the client’s management are added to four columns next to the client’s name. This board facilitates communication between the different members of the inter-professional team. The goals for the client’s rehabilitation are discussed weekly with an inter-professional team and is facilitated by the occupational therapist and physiotherapist. Referrals to appropriate services not delivered at BLRC are also discussed and done as required. • Therapeutic and rehabilitative groups. Clients receive holistic input from inter-professionally designed group programmes to address all their rehabilitation needs. Students have the opportunity to either present part of the programme or shadow other professionals presenting it. • Home/work visits. As part of a client’s holistic rehabilitation, they are also treated in their home and work environment as needed. At least two different professionals should conduct the visit, which gives students the opportunity to experience the role/scope of other professions. • Community outreaches. Training of home-based carers and volunteers, and health education talks, are planned and implemented interprofessionally. Students of at least two of the four professions are responsible for the planning and implementation of this service. The national health calendar and four seasons of health-promotion documents are used for planning the monthly themes covered in health education. All administrative duties at BLRC are done in an inter-professional manner, e.g. documenting progress notes in one file per client, and co-ordinating the scheduling of clients’ appointments in diaries, as this ensures time- and cost-effective services.

Methods and analysis

This qualitative study describes students’ experiences of inter-professional learning. Data were obtained from anonymous student feedback forms. At the end of their clinical placement at BLRC, students were requested to fill in feedback forms as part of the quality assurance process to optimise learning opportunities. The completion of student feedback forms is voluntary and anonymous and students were allowed to independently answer questions in a private area after completion of their final evaluation. The feedback forms contained open-ended questions about their learning experience at BLRC, e.g. highlights and barriers of the clinical placement. No specific questions about inter-professional learning were included. Convenience sampling was employed and all students completing clinical placement at BLRC between 2010 and 2012 who handed in their forms were included in the study. A total sample of 124 out of a possible 209 students was obtained (DT: n=32; OT: n=46; PT: n=36; SLT: n=10). Ethical approval for using the data was obtained from the SU Health Ethics Research Committee (X13/12/018). The anonymity of the students was maintained throughout data collection and no identifying information was used on the feedback forms during analysis.

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Credibility of the data collection process was ensured by employing triangulation of data sources, as the collection time spanned over 3 years and consisted of four different groups of health professions students.[14] These qualitative data were analysed by employing an inductive approach, and three key themes relating to inter-professional work were identified. Credibility, transferability and dependability were applied during the data analysis process to ensure trustworthiness of the findings. Credibility was obtained by applying theoretical triangulation through reviewing of the most recent literature confirming or contradicting the themes that emerged from the data analysis. The coding of data was done by one of the researchers not involved in the supervision of the students, and peer review by the other three researchers by generating their own code lists, which were then compared with those of the first researcher. These codes were discussed and altered until consensus was reached.[14] Transferability and dependability were obtained by giving a detailed description of the participants, research methodology and setting to determine applicability to a different setting and by using a sample of convenience.[14]

Results

More than half of the students spontaneously answered that ‘working in an inter-professional team’ was a highlight of their placement at BLRC. Students felt that they learned a great deal about the role of other professions in the management of their clients and about the role of their profession. The three themes that emerged are described below and are illustrated by direct quotes from the different professionals. Theme 1. Inter-professional teamwork Inter-professional teamwork encompasses the important aspects of clear communication between all, learning to work with one another and to respect the input of all towards addressing the needs of the client. ‘Everyone gets an opportunity to give input on what would be best ... it felt like they did value our discipline in order to give the best to the patient.’ [DT, 2012] ‘I have learned a lot ... how important it is to communicate so that the different professions can complement each other.’ [OT, 2012] ‘To experience the way the multi-professional team should work together was a very good learning opportunity.’ [PT, 2011] ‘A good learning experience to be put in that situation and learn how to work with other professionals.’ [SLT, 2012] Theme 2. Role identity of own profession This theme alludes to the important realisation by students of the scope of practice of their profession and affirmation of their career choice. ‘During the meeting I realised that dietetics has a strong focus on treatment and prevention but also includes rehabilitation, whilst the physio, occupational and speech, language and hearing therapists' biggest focus was rehabilitation.’ [DT, 2012] ‘Working with all the different professions ... I feel much more confident ... that OT is what I want to do and why it is such a fulfilling occupation.’ [OT, 2012] ‘... helped me to learn in different ways, helped me to grow and contributed to my positive experience ... .’ [PT, 2011] ‘Ultimately it made me a better therapist. It made me rethink my therapy goals and approach to therapy.’ [SLT, 2011]

Research Theme 3. Role of other professions The importance of learning from one another and to take cognizance of the role and inputs of other professions are highlighted in this theme. ‘… was a nice learning experience where I got to see what other roleplayers of the inter-disciplinary team do.’ [DT, 2012] ‘Working with all the different professions’ students and seeing where everyone fits into the team.’ [OT, 2012] ‘I enjoyed working with the multi-professional team and I was able to learn more about OTs and SLTs and when referrals might be appropriate in the future.’ [PT, 2011] ‘Listening to other professionals and understanding what their role is.’ [SLT, 2012] The activities mentioned by students within these themes, which they noted as contributing to their learning opportunity while doing practical training at BLRC, were weekly inter-professional team discussions, group therapy sessions, home visits and team socials.

Discussion At BLRC, the WHO ICF model is used because of its inclusive focus on health, well-being and functioning, ensuring optimal care for individuals and the community. The ICF is therefore also acknowledged internationally as being suitable for educational and training purposes. Although the different disciplines involved at BLRC have their specific scope of practice, the ICF model allows them to work collaboratively to achieve and provide holistic care for their clients. The use of the ICF model guided and aligned assessment and management of clients by students from different professions, and then assisted in the collaborative planning of the diverse, profession-specific, yet suitable, interventions. The Lancet’s Global Independent Commission into the Education of Health Professionals for the 21st century suggests that inter-professional education is one of the methods that will ensure effective teamwork.[1] The three themes identified in this study describe professional attributes that are important outcomes of inter-professional practice as well as essential qualities to achieve optimal and holistic client care that is realised when using the ICF model. Through their inter-professional teamwork, the students reported that they had not only developed a strong understanding of their own unique role and expertise, but also respect for each other’s roles and contribution towards client care. The themes identified are not unique, as Nisbet et al.[6] also reported the vital role of IPE to assist students in developing effective interprofessional communication and teamwork competencies.

Further research is necessary to investigate the full potential of ICF as a framework to support the IPE philosophy in a clinical setting.

Conclusion

It seems as though the manner in which the Centre is managed, with weekly inter-professional team discussions, team socials, joint home visits and treatment sessions, with the ICF model guiding client-directed activities, spontaneously lends itself to IPE between students from different professions. ICF-based activities not only ensured a holistic approach to client care, but also facilitated students learning from other professions and about their own profession. No specific information was requested regarding IPE in the feedback forms provided to the students. More than half of the students spontaneously mentioned learning about working in an inter-professional team as one of the highlights while at BLRC, which prompted us to share this information. The value of this article is that it offers a potential framework (ICF) that fosters and supports the IPE philosophy in a clinical setting. Further investigation into the range and depth of this learning experience has been initiated.

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. Dhai A, Mkhize B. The Health Professions Council of South Africa and the medical practitioner. Continuing Medical Education 2006;24(1):8. 3. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Care Professions – General Ethical Guidelines for the Health Care Professions. Booklet 1. The Human Rights, Ethics and Professional Practice. Pretoria: HPCSA, 2008. 4. Declaration of Alma-Ata. International conference on primary health care, Alma-Ata, USSR, 1978. http://www. who.int/publications/almaata_declaration_en.pdf (accessed 23 January 2015). 5. Schaay N, Sanders D. International perspective on primary health care over the past 30 years. In: Barron P, RomaReardon J, eds. South African Health Review 2008. Durban: Health Systems Trust, 2008:3-16. 6. Nisbet G, Hendry GD, Rolls G, Field MJ. Interprofessional learning for pre-qualification health care students: An outcomes-based evaluation. J Interprof Care 2008;22(1):57-68. [http://dx.doi. org/10.1080/13561820701722386] 7. CAIPE. Interprofessional education – a definition. 2002. http://www.caipe.org.uk/resources/ (accessed 27 September 2012). 8. Lê Q, Spencer J, Whelan J. Development of a tool to evaluate health science students’ experiences of an interprofessional education (IPE) programme. Ann Acad Med Singapore 2008;37(12):1027. 9. De Villiers MR, Asia MB, Dreyer MY, Koornhof MHE, Statham MS. Training the primary health care team. SA Fam Pract 1996;17(3):111-117. 10. World Health Organization (WHO). Towards a Common Language for Functioning, Disability and Health ICF. Geneva: WHO, 2002. http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf (accessed 27 September 2012). 11. Kloppers M. Die uitkomste wat fisies-gestremde kliënte bereik deur hul deelname aan rehabilitasie by ‘n gemeenskapsrehabilitasiesentrum in die Wes-Kaap. Stellenbosch: Stellenbosch University, 2012 (unpublished dissertation). 12. Western Cape Department of Health. Re-engineering of primary health care for South Africa. 2012. http://www. uwc.ac.za/usrfiles/users/280639/CHW_symposium-NationalPHC_Reengineering.pdf (accessed 27 September 2012). 13. De Villiers MR, Dreyer Y, Howes F, et al. Assessing the health needs of a community through participatory research. SA Fam Pract 1999;21(1):8-12. 14. Krefting L. Rigor in qualitative research: The assessment of trustworthiness. Am J Occup Ther 1991;45(3):214222. [http://dx.doi.org/10.5014/ajot.45.3.214]

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Research Perceptions of physician leadership in Botswana L Sokol-Hessner,1 MD; B M Tsima,2 MD; C J Dine,3 MD; B Masheto,4 MD; J A Shea,3 PhD; J Masunge,4 MD; O Nkomazana,2 MB ChB, FCOphth, MSCEH 1

University of Pennsylvania, Internal Medicine Residency Program, Global Health Track, Philadelphia, USA

University of Botswana School of Medicine, Gaborone, Botswana

University of Pennsylvania, Department of Medicine, Philadelphia, USA

Nyangabgwe Referral Hospital, Francistown, Botswana

Corresponding author: L Sokol-Hessner (lhessner@bidmc.harvard.edu)

Background. Physician leadership is essential for the strengthening of health systems, especially in underserved settings such as sub-Saharan Africa. To be effective, leaders must be perceived as such by their community. It is unknown how perceptions of physician leadership in Botswana compare with those of the Canadian Medical Education Directives for Specialists (CanMEDS) Physician Competency Framework, which is used to shape the training of Botswana’s future physicians. Objective. To examine if the perceived competencies of physician leadership in Botswana are specifically named in the CanMEDS Framework and thereby inform Botswana’s graduate medical education. Methods. We conducted focus groups discussions with nurses, interns, medical officers and specialists at Princess Marina Hospital and Nyangabgwe Referral Hospital. Key questions focused on describing the qualities of physician leadership. For data analysis we used inductive content coding and comparison with the CanMEDS frameworks. Results. Forty-eight clinicians participated and 111 unique codes were assigned to 503 comments. Eighty-four per cent of comments corresponded to the CanMEDS 2005 competencies; many were captured within the competencies of the medical expert (13.0%), communicator (17.8%), collaborator (15.6%), scholar (14.9%) and professional (31.3%) roles. About 5% of comments mapped to the draft CanMEDS 2015 update, and 11.5% were not specifically described in either version of CanMEDS, including charisma and decisiveness. Conclusion. The CanMEDS frameworks specifically address most of the competencies perceived as important for physician leadership in Botswana. Additional perceptions were identified that may require the attention of existing and aspiring physician leaders and their teachers to ensure they attain and maintain their effectiveness as leaders. Afr J Health Professions Educ 2015;7(1):26-31. DOI:10.7196/AJHPE.312

Botswana has significant healthcare challenges; the effects of the ‘brain-drain’ and HIV in southern Africa have been well described. Effective leadership is required to successfully strengthen Botswana’s health system and address these challenges. However, there is a persistent need for more leadership in healthcare, especially in underserved areas.[1,2] Physicians have a unique role in health system improvement, given their significant influence.[3,4] Some have specifically called for physicians to be ‘change agents’ who drive the strengthening of health systems.[3-6] Fortunately, there is a growing consensus that physicians can be taught leadership skills.[1,7,8] Graduate medical education (GME) is an ideal time and setting to begin teaching leadership, as many physicians first exercise their leadership skills in the clinical training environment.[7,9] In Botswana, the recent establishment of a number of residency programmes highlights the ideal time to investigate physician leadership. Medical educators aim to train physicians towards a set of competencies. For example, in Botswana the residency programme curricula have been informed by the Canadian Medical Education Directives for Specialists (CanMEDS) Physician Competency Framework, developed by the Royal College of Physicians and Surgeons of Canada in the 1990s, updated in 2005 and currently being updated for 2015.[10,11] Other medical education organisations utilise similar competency frameworks.[5,12,13] While GME traditionally focused on clinical training, these frameworks include additional competencies. Even though the frameworks are comprehensive, competent physicians are not necessarily effective leaders. The reason may be found in the most

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widely cited (neocharismatic) leadership theories, including the hypothesis that for leaders to be effective they must be perceived to be leaders by those they lead.[14] Having the competencies of a physician, may not be sufficient to ensure effectiveness as a leader. An important question for Botswana is whether the use of CanMEDS alone will produce not only competent physicians, but also effective physician leaders. If physician leadership is perceived differently in Botswana from what is explicitly described in the CanMEDS framework, these differences could inform the GME curriculum. To date, the CanMEDS 2015 update has had only limited input from one southern African country (CanMEDS administrative staff (canmeds@royalcollege.ca), question about CanMEDs, 2014 – personal communication). Alternatively, if perceptions of physician leadership are well described by CanMEDS, it would lend validity to use of the framework to shape physician leadership education. While CanMEDS 2005 and the draft 2015 update include the concept of leadership, both tend to describe it in nonspecific terms (Appendix 1). Understanding perceptions of physician leadership in Botswana could deepen our understanding of the terms used in the frameworks, such as ‘collaborative leadership', 'followership’ and ‘personal leadership skills’. To understand perceptions of physician leadership in Botswana, we focused on Botswana’s two main teaching hospitals, Princess Marina Hospital (PMH) in Gaborone and Nyangabgwe Referral Hospital (NRH) in Francistown. We concentrated on perceptions of physicians in internal medicine because of their primary roles in the academic hospital environment, and as internal

Research medicine was one of the first residency programmes introduced at the University of Botswana. We also included nurses, as they have traditionally held many of the leadership positions in Botswana’s health system and work closely with physicians at all levels of training.[15]

Table 1. Focus group perceptions specified by CanMEDS 2005, N=422 (83.9%)* Medical expert, n=55 (13.0%) Is knowledgeable, smart, or competent

Methods

Is humble

Has practical skills

We conducted focus group discussions in March 2010. All participants worked in the medical wards at PMH and NRH and voluntarily took part after being recruited via verbal announcements on the wards by study investigators. Each focus group consisted of one type of medical professional (nurses, interns, medical officers and specialists) at each of the two hospitals for a total of eight groups. Interns have completed medical school and medical officers have completed an internship, while specialists have completed a residency. The ethical committees at the Botswana Ministry of Health, PMH, NRH, and the University of Pennsylvania approved the project.

Spends time with patients

Examines patients (i.e. ‘laying on of hands’)

Treats patients holistically

Has good judgement

Acknowledges shortcomings

Is resourceful

Is knowledgeable about patients

Is knowledgeable about traditional medicine

Is hands-on

Applies knowledge in context

Is cautious

Study design and participants

Procedures and statistical analysis

We designed the moderator script to elicit participants’ perceptions of qualities necessary for physician leadership. The focus group guide from previous work[16] was reviewed by researchers familiar with qualitative research in Botswana. In the lead question participants had to recall a scenario where they either acted as or observed a physician leader and describe the qualities that made the physician a good leader. Discussion was primarily in English – the official language of the hospital environment – but participants were encouraged to express themselves in the local language (Setswana), if preferred. We recorded and transcribed each session, and a reviewer from Botswana translated as necessary. Inductive content coding was used to analyse the data. Two persons (BM, LSH) reviewed transcripts and analysed text content to identify the main themes. An iterative process of revision was used to develop a coding scheme, which was then approved by the entire research team before training a third reviewer (BMT) who was not involved in creating the scheme. Two reviewers (BMT, LSH) then worked independently to recode each transcript, and differences in coding were reconciled collaboratively. Where the reviewers could not reconcile their differences, the coding by the reviewer from Botswana was used for the final analysis. Trustworthiness of the analysis was examined by member checking and comparing the themes to leadership models from previous work. We then compared the focus group comments with the language used in the CanMEDS 2005 Physician Competency Framework and the publicly available information about the upcoming CanMEDS 2015 update. Comments that were not clearly represented in either of the CanMEDS versions were organised into categories informed by a review of the physician leadership literature.

Results

Fifteen nurses, 12 interns, 12 medical officers, and 9 specialists participated. Nineteen of the participants were from PMH and 29 from NRH. Twentyfive (52%) were women. Inductive content coding generated 111 unique codes in our coding scheme; these were assigned to 503 comments. Kappa ranged from 0 to 1.0, and a median of 0.66. Some participants discussed leadership in the contexts of education, administration or research scenarios, but most described physician leaders in terms of their role in healthcare teams. Table 1 shows the number and percentage of comments and the CanMEDS 2005 roles with which

Communicator, n=75 (17.8%) Listens

Is approachable

Communicates

Communicates with colleagues

Communicates with patients

Communicates proactively

Communicates with patients in terms they understand

Communicates with relatives

Justifies his/her reasoning

Respects patient beliefs or opinions

Respects patient confidentiality

Is empathetic or reassuring

Avoids unnecessary barriers between themselves and patients

Addresses patient concerns

Is transparent

Documents properly

Collaborator, n=66 (15.6%) Is not a dictator and does not abuse power

Asks for and considers input from colleagues, even subordinates

Works well in teams

Is knowledgeable about the team

Relates well with others

Addresses and solves problems

Does not humiliate

Has the interest of the team in mind or promotes team spirit

Is proactive or takes initiative

Is willing to learn from colleagues

Delegates

2 Continued ...

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Research

Table 1. (continued) Focus group perceptions specified by CanMEDS 2005, N=422 (83.9%)*

Collaborator (continued)

Professional (continued)

Searches for underlying problems

Has good morals or is a good person

Is able to take direction from others

Has botho

Manager, n=21 (5.0%)

Is reliable

Is organised

Is accountable

Is knowledgeable about the work environment or system

Is non-judgemental

Is disciplined or focused

Is compassionate

Is able to navigate the system they work in

Is able to control their emotions or manage their personality

Health advocate, n=10 (2.4%)

Acknowledges mistakes

Advocates for patients

Is non-racial

Is knowledgeable about the community

Balances confidence and humility

Is knowledgeable about the culture

Is presentable

Collaborates with communities

Meets targets

Is respected by the community

Scholar, n=63 (14.9%) Gives constructive feedback

Is determined

Guides others

Is forgiving

Is willing to learn

Is flexible

Teaches

Accepts criticism

Acknowledges achievements and appreciates others

Does research

Keeps up to date

Is academic

Encourages

Practises evidence-based medicine

Gives feedback

Is a mentor

Is willing to change

Seeks constant improvement

Is reflective or evaluative

Gives advice

Professional, n=132 (31.3%) Is professional†

Is fair or impartial

Respects and values others

Is a model or leads by example (i.e. exemplary)

Is committed or dedicated

Is hard working

Is honest or straightforward

Takes responsibility

Is accessible

Is thorough

Is patient

Is trustworthy

4 Continued ...

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*Number of comments; denominator for % is all comments. † Always conduct themselves as a leader, even in situations where they have not been formally appointed.

they matched best. Within that group of comments, most focused on the competencies of the medical expert (13.0%), communicator (17.8%), collaborator (15.6%), scholar (14.9%) and professional (31.3%) roles and very few on the health advocate or manager role. An additional 4.6% of all comments were best matched to the draft 2015 update (Table 2), and 11.5% of comments did not fit easily into either version of CanMEDS (Table 3). Below we expand upon themes.

Perceptions of physician leadership and CanMEDS 2005

Medical expert Being a medical expert was very important to participants – they commented on the importance of being knowledgeable, smart and competent 21 times, the single most common comment overall. Practising comprehensive patient care, including ‘taking time with the patient’, being aware of alternative medicine and applying knowledge in the socioeconomic context were also seen as important aspects of leadership. Communicator Communication had many aspects: ‘You should have good communication skills, to the patients, to your subordinates … to … your superiors’. Listening well and approachability were key: ‘There should be no fear of being reprimanded’. As one participant said, ‘[proactive communication] should start on admission, straight away until discharge’. Collaborator Respect, support and encouragement were fundamental to teamwork: ‘… help us feel that … you can see how we are struggling to make things better … show appreciation to [the team]’. Not being a ‘dictator’ was mentioned many times: ‘Often people … turn leadership into a dictatorship, thinking that they will succeed, and that’s very dangerous’.

Research

Table 2. Additional focus group perceptions of physician leadership specified in the draft CanMEDS 2015 update. New CanMEDS 2015 language not present in the 2005 version is delineated in italics, N=23 (4.6%)* Medical expert

7 (30.4%)

Promotes accountability or holds others accountable

Enabling competencies: 4.1 Establish the roles of the patient and all team members for follow-up on investigations, response to treatment, and consultations, and ensure that the agreed follow-up occurs Leader (previously manager)

14 (60.9%)

Has a vision or plan

Sets expectations or targets

Role description: At a system level, physicians contribute to the development and delivery of continuously improving healthcare and engage others to work with them toward this vision Scholar Is innovative or creative

Table 3. Additional focus group perceptions of physician leadership not specified by CanMEDS 2005 or the 2015 draft, N=58 (11.5%)* Charismatic

26 (44.8%)

Is inspiring or motivating

Unifies

Is passionate about their work

Is friendly

Is likeable

Has a good attitude

Decisive

29 (50.0%)

Is confident or assertive

Is decisive or takes a stand

Is firm

Miscellaneous

3 (5.2%)

Is experienced

2 (8.7%)

Distinguishes themselves

*Number of comments, denominator for % is all comments.

Key concepts: Clinical innovation There were no additional comments mapping to the communicator, collaborator, health advocate or professional roles. *Number of comments, denominator for % is all comments.

Participants felt strongly that leaders should search for underlying problems and their solutions, as one participant explained: ‘When there is a problem, a good leader should be bold enough to … confront it’. The ability to delegate was essential: ‘A good leader … has to be able to use the mind of others … he has to know how to utilize those under him’. Asking for help was perceived as a strength: ‘[a leader] shouldn’t be … shy to ask … for a second opinion if he feels he’s failing … they should accept opinions from their subordinates’. Manager There were few comments about being a manager. Several participants said: ‘It’s very essential, as a … good leader, to manage your time’. Understanding the work environment and healthcare system was of strategic importance: ‘Research about everything that is … happening, like in the unit that you are’. Another said: ‘Even when the system is very difficult, you have to find your way … around the system’. Health advocate There were also very few comments about this role. One participant said: ‘You have to have your patient’s best interest, everything will come from that’. Another explained: ‘If you see a need for that patient to be done … you have to convince whoever is against that idea that it should be done for the patient’. Scholar The importance of seeking constant self-improvement was described in several ways, especially with regard to being up-to-date and evidence based: ‘I think also you have to be academic. They have to know what the latest journals are saying … because as a leader, you should be able to make such decisions when your juniors come [to you with questions].’ Other participants emphasised teaching and giving feedback: ‘You should be able

to be a good teacher … because [your students] are going to end up where you are’. ‘A good leader is one who comes to you and says, “I think you need to improve on these areas”.’ Being a mentor, giving advice and guiding others were also important: ‘You … have a group of young … newly qualified doctors who have no clue what the world of medicine is like … you need to mentor it’. Another participant said: ‘For me a leader is the one who guides, or who shows where is the path, the route’. Professional Of all the CanMEDS roles, the professional was mentioned most (26% of all comments), and participants were most impassioned about this role: ‘In medicine you should expect somebody to assume some level of professionalism … we deal with human beings, you miss a boat, somebody loses their life’. Many noted that leaders always conduct themselves as such, even when they are not in a formal leadership role. Other aspects of being a professional included commitment, work ethic, honesty, fairness, impartiality, a sense of morals and accountability. Participants also mentioned leaders needing to have botho. One of Botswana’s former presidents said: ‘Botho is a state of being humane, courteous and highly disciplined ... the value attached to life is central to the principle of botho’.[17] A focus group participant said: ‘Botho [means] you know how to treat every human being right, and you know to respect everything’. Being a role model was mentioned many times: ‘A leader should live an exemplary life … because if you just act professionally in front of the people you are leading, and outside that, you act like … somebody I don’t know, I want to take you as a pretending leader’. The importance of leading by showing was described several times: ‘Before people follow you, you must be a model … if I expect my houseman to work up until 5:30, I must also be willing to work … . I expect my houseman to do a lumbar puncture, I should be able to do a lumbar puncture.’ Leaders also needed to have humility and balance: ‘You should be cautious of what conclusions you reach’; another said: ‘That’s the … leadership skill, to know how to react, you need to know when to be flexible, but you need to know when to put your foot down as well’.

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Research Perceptions of physician leadership and the draft CanMEDS 2015 update Medical expert The updated language in one of the enabling competencies refers to the concept of accountability (Table 2). A participant said: ‘Part of what leaders do also is help other people be accountable, not just themselves’. Leader (formerly manager) The authors of the Expert Working Group for the manager role in the 2005 framework decided to change the name of the role to leader for the 2015 update and for the first time included the concept of vision. ‘… a good leader is one who would have … short term and long term goals.’ An example of how to set targets to engage one’s team was: ‘Ok, I can see that this is the way that things are being done, but my dream and my goal is for us to develop in this field and ultimately move to … this level. So how can we reach that level?’ Another said, ‘I also think a good leader should have a vision … so that he’s able to guide his team where … they are going in the right direction’. Scholar The key concepts for this role in the 2015 update include innovation, and one of the participants said: ‘A good leader should also be innovative. Bringing in new ideas’.

Additional perceptions of physician leadership

There were a number of comments on perceived qualities of physician leadership that were not clearly identified in CanMEDS 2005 or the draft 2015 update. Charismatic The ability to be a positive figure was identified many times: ‘For you to inspire other people, you should show passion to your work. You shouldn’t be called to come and do your work. You should come and look for work.’ Physician leaders ‘get people to do stuff, but … they don’t fight with them … they just make things happen’. Another participant offered a key insight: ‘[the leader] may have a very brilliant idea, but if she comes and says … it’s her idea [then we won’t do it] … but if she comes and puts it on the table, we discuss, it becomes our idea … then we will do it all’. Decisive There were >30 comments about having a ‘strong personality, somebody who … is … comfortable with [themselves]’. Participants felt this was necessary for teams to have confidence in their leaders.

Discussion

Our study is the first to describe the overlap between the perceived competencies of physician leaders and an existing GME competency framework used in Botswana and much of southern Africa. Eighty-four per cent of the comments by focus group participants were consistent with the CanMEDS 2005 framework, while 5% were consistent with language found in the draft 2015 update. These focused on the concepts of vision – which has been noted in multiple other physician leadership studies[4,7-9] – and promoting accountability. The results suggest that training physicians according to the CanMEDS framework, especially after the 2015 update, will cover most of the perceived competencies for effective physician leadership. Although more comments were consistent

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with the professional than any other role, the single most common comment was about being a knowledgeable, smart, competent medical expert. The centrality of medical expertise for physician leaders has been previously noted[3,16] and was validated by our participants, who primarily referred to physician leadership in the context of clinical teams in the hospital. Beyond the perceptions that matched well with the two versions of CanMEDS, we found that >11% of comments were about charisma and decisiveness. Neocharismatic leadership theories are the most widely cited outside of medicine;[14] therefore it is not surprising that our focus groups perceived charisma to be important. To date, the concept of decisiveness has not been a prominent part of the leadership literature and may be worth investigating further. Nevertheless, the perceptions not captured in the CanMEDS frameworks may be part of how healthcare providers in Botswana would consider the terms ‘collaborative leadership’, ‘followership’ and ‘personal leadership skills’, which are used by the authors of the CanMEDS 2015 update. Notably absent from the comments were the roles of health advocate and manager. Although it is not clear why these roles were emphasised less often, it is not a novel occurrence. An evaluation of the CanMEDS framework in Canada found that many programmes had not used the health advocate or manager roles in their curricula as often as the other roles.[10] Based on other physician leadership work, especially focusing on administrative and executive leadership positions, we know that these roles are often very important and therefore may require additional attention when designing curricula.[4,9] Future work may explore why participants did not mention these skills more frequently. Our study had several limitations. We only investigated one setting with a limited number of providers, which may limit the generalisability of the results to other contexts. This is mitigated somewhat by the similarities between the leadership competencies identified and those described in previous work.[7,16] Secondly, although clinicians in Botswana are from many different cultures, our study was not designed to determine how these cultures may view physician leadership. Awareness of cultural differences may be an important part of developing effective physician leadership assessment tools and training programmes.[4] Thirdly, participants in focus groups may have been unwilling to discuss certain characteristics in the presence of others. Attempts were made to minimise this effect by ensuring that groups were composed only of colleagues of the same clinical training, emphasising anonymity of comments, and conducting groups in a non-judgemental way.

Conclusion

Our research on perceptions of physician leadership demonstrates good congruence with the GME framework used in Botswana and reveals insights that can inform aspiring and established leaders and their teachers. Some have been sceptical about whether the competencies of physician leadership can be taught,[8] but as we have shown, most of what nurses, interns, medical officers and specialists in Botswana perceive as important for physician leadership are already part of GME curricula. Future work could include the use of innovative educational methods, such as structured individualised learning plans to teach and reinforce leadership competencies.[4,7,9,18] In addition, the development of physician leadership assessment tools could strength physician leadership training.[9,18] Competencies that are measured will be more highly valued, both by educators and students.

Research References 1. Levey S, Hill J, Greene B. Leadership in health care and the leadership literature. J Ambulatory Care Manage 2002;25(2):68-74. 2. O’Neil ML. Human resource leadership: The key to improved results in health. Hum Resour Health 2008;6(1):10. 3. Reinertsen JL. Physicians as leaders in the improvement of health care systems. Ann Intern Med 1998;128(10):833-838. 4. Farrell JP, Robbins MM. Transformational leadership. Leadership competencies for physicians. Health Forum J 1993;36(4):39-42. 5. Scottish Deans’ Medical Curriculum Group. The Scottish Doctor. 2007. http://www.scottishdoctor.org/ (accessed 29 December 2014). 6. 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] 7. Kuo AK, Thyne SM, Chen HC, West DC, Kamei RK. An innovative residency program designed to develop leaders to improve the health of children. Acad Med 2010;85(10):1603-1608. [http://dx.doi.org/10.1097/ ACM.0b013e3181eb60f6] 8. Taylor CA, Taylor JC, Stoller JK. Exploring leadership competencies in established and aspiring physician leaders: An interview-based study. J Gen Intern Med 2008;23(6):748-754. [http://dx.doi.org/10.1007/s11606-008-0565-5] 9. Crites GE, Ebert JR, Schuster RJ, Shuster RJ. Beyond the dual degree: Development of a five-year program in leadership for medical undergraduates. Acad Med J Assoc Am Med Coll 2008;83(1):52-58.

10. Frank J, ed. The CanMEDS 2005 Physician Competency Framework. Better Standards. Better Physicians. Better Care. Ottowa: The Royal College of Physicians and Surgeons of Canada, 2005:9-24. 11. Frank J, Snell L. Draft CanMEDS 2015 Physician Competency Framework – Series I. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2014. http://www.royalcollege.ca/portal/page/portal/rc/common/ documents/canmeds/framework/framework_series_1_e.pdf (accessed 29 December 2014). 12. ACGME. Common program requirements: General competencies. 2007. http://www.acgme.org/outcome (accessed 29 December 2014). 13. General Medical Council. Tomorrow’s doctors – outcomes and standards for undergraduate medical education. 2009. http://www.gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf (accessed 29 December 2014). 14. Dinh JE, Lord RG, Gardner WL, Meuser JD, Liden RC, Hu J. Leadership theory and research in the new millennium: Current theoretical trends and changing perspectives. Leadersh Q 2014;25(1):36-62. 15. Dube A, Jooste K. The leadership characteristics of the preceptor in selected clinical practice settings in Botswana. Curationis 2006;29(3):24-40. 16. Dine C, Kahn J, Abella B, Asch D, Shea J. Key elements of clinical physician leadership at an academic medical center. J Grad Med Educ 2011;3(1):31-36. [http://dx.doi.org/10.4300/JGME-D-10-00017.1] 17. Mogae F. His Excellency Mr Festus Gontebanye Mogae, President of the Republic of Botswana, Independence Day message to the nation. 2003. http://www.botswanaembassy.org/092903_1.html (accessed 29 December 2014). 18. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287(2):226-235.

Appendix 1. Use of the word ‘lead’ in the context of leadership, in the CanMEDS 2005 framework and draft 2015 update CanMEDS 2005 Collaborator – Enabling Competencies – 1.10. Where appropriate, demonstrate leadership in a healthcare team Manager – Enabling Competencies – 4. Serve in administration and leadership roles, as appropriate. 4.2. Lead or implement a change in healthcare Draft CanMEDS 2015 Rename Manager Role to Leader Definition: ‘As leaders, physicians develop, in collaboration with other healthcare leaders, a vision of a high-quality healthcare system and take responsibility for effecting change to move the system toward the achievement of that vision’ Major content changes include: ‘Although diverse opinions were expressed, common ground was found with regard to the need for physicians’ personal responsibility, active engagement, and contribution (as ways of conceptualizing leadership)’ Key concepts include: ‘collaborative leadership’, ‘followership’, ‘leading change’, and ‘personal leadership skills’ Key competencies include 3. Demonstrate leadership in professional practice 3.1 Develop their leadership skills 3.2 Facilitate change in healthcare to enhance services or outcomes 3.3 Design and organise elements of healthcare delivery

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Research Identity and attribution as lenses to understand the relationship between transition to university and initial academic performance W McMillan, BPrimEd, BEd, PGDip (PP), DEd Faculty of Dentistry, University of the Western Cape, Tygerberg Campus, Cape Town, South Africa Corresponding author: W McMillan (wmcmillan@uwc.ac.za)

Background. Most students experience the transition from school to university as challenging. First-generation students are particularly vulnerable, as they receive little preparation for the expectations of university. Objective. To understand the relationship between preparation for university, transition experiences, and academic performance in the first two years at university. Methods. Sixteen second-year dentistry students were interviewed in this qualitative pilot study. Their marks for the first 18 months at university were accessed. Two theoretical frameworks were used to analyse the data – academic identity and attribution. Analysis resulted in four groupings: academically competent middle-class students, academically struggling middle-class students, academically struggling working-class students and academically competent working-class students. Results. Findings suggest that students’ academic performance is influenced by social class and assumptions of controllability and causality. Assumptions about control over their environment influenced how they engaged at university. These assumptions resulted in some students being better positioned for integration into the practices rewarded at university. Irrespective of social class, those who attributed academic performance to factors outside their control performed less well. Conclusion. The study suggests that interventions are required that help all students to control their academic performance. Attributional retraining (AR) has the potential to assist students who attribute academic performance to causes beyond their control. The article concludes with suggestions for ways in which AR might be implemented to assist all students towards obtaining competent academic performance. Suggestions are also made for further large-scale studies. Afr J Health Professions Educ 2015;7(1):32-38. DOI:10.7196/AJHPE.356

Most students struggle with the transition from school to university[1] because the latter expects and rewards different academic practices from those valued at school.[2] Students who are the first in their families to attend university are the most vulnerable, as they have little opportunity to anticipate or prepare for the challenges of higher education.[3]

Objectives

The objective of this study was to understand the relationship between students’ experiences of school-university transition and academic performance. This article offers insight into how transition is experienced by students who are first in their families to attend university and those who come from schools and families that prepared them for university. It explains the manner in which students engage with the university’s academic environment by examining students’ assumptions about their control over this environment. The article shows how these assumptions result in some students being better positioned for integration into the practices rewarded by university. The article then concludes by drawing on insights from the study to make recommendations for supporting all students in their transition from school to university.

Literature review

Two theoretical frameworks were used to understand students’ engagement with the academic environment and their assumptions about academic success.

Identity

Wendt[4] defines identity as ‘role-specific understandings and expectations about self ’, which are acquired ‘by participating in … collective meanings’.

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Identities are fastened, unfastened and refastened in cultural spaces[5] – in the case of this study, in schools and universities. Identity fastening occurs through the activities in which people engage to be recognised as insiders.[5] Students enter university with the fastened academic identity of ‘school learner’, which encompasses the practices expected and rewarded at school. Identity unfastening occurs when people are required to take on and demonstrate the practices of a different cultural context.[5] Achieving success at university requires competence in practices that are usually different from those engaged in at school. Identity refastening occurs when new practices are incorporated into current practices or when they replace existing practices.[5]

Attribution

Attributions are the causal explanations that people give of their experiences.[6] These explanations depend on people’s beliefs with regard to their own capacity to predict and influence their environment.[6] Attribution theory is used to explain how individuals use the information they gather about their experiences to form causal judgements.[6] Attribution theory has been used to understand how university students draw on personal perceptions to explain academic performance.[7] Two concepts from attribution theory which have been used to understand higher education are pertinent to the study – causality and controllability. Causality refers to the explanation that students give regarding the causes of their performance.[6] Students who assume an internal locus of causality explain performance with reference to internal factors, such as skills, ability and effort.[6] Those who assume external locus of causality attribute performance to external factors, such as task difficulty and luck.[5] Controllability refers to students’ perceptions of whether the cause of their performance is within their control.[5] Students who perceive themselves as having control over their performance (i.e.

Research controllability within) attribute success or failure to effort.[5] Students who perceive performance to be beyond their control (i.e. controllability without) attribute success or failure to luck or the actions of others. Students who believe that they are in control perform better academically than those who do not have this belief.[7]

This qualitative pilot study examined the relationship between academic identity, perceptions of causality and control, and academic performance for a group of students at a South African university. Qualitative research allows for complex descriptions of people’s experiences.[8] The qualitative approach allowed insight into students’ transition experiences and their explanations of their performance.[8] A pilot study design was selected as this was an exploratory study. Findings from exploratory studies have the potential to highlight salient issues for large-scale confirmatory studies.[9] The study elicited students’ retrospective perceptions of the school-university transition and examined their explanations of academic performance. The pilot cohort consisted of 16 dentistry students in their second academic year. The cohort comprised eight of a group of 11 students who had participated in transitionexperience focus-group interviews the previous year, and a further eight who joined the cohort in their second academic year. All 16 came from a single class of 23 firstyear dentistry students. In their first year, all 94 dentistry students were randomly allocated to one of four smaller classes for a core module. One of these classes, comprising 23 students, was selected for the pilot study. The cohort encapsulates a relevant range in relation to the wider population of first-year dentistry students at the study site because of the random allocation of students to smaller classes.[10] Table 1 indicates academic performance, social class and race of cohort members. The final percentages for first-year modules and modules completed in the first semester of the second year were elicited to understand students’ academic performance during their transition period and at the time of the interviews. The terms African, Indian, coloured (mixed race), and white are racist nomenclature of apartheid. The legacy of apartheid, and its disparate distribution of resources along race lines, has resulted in a classed post-apartheid society based predominantly on previously racialised divides.[11] The use of race terms in this study highlights that legacy. For the study, ‘working class’ was used to signal students whose home and school were located in working-class areas, who were first in their family to attend university, and who were funded by the National Student Financial Aid Scheme available to students from low-income families. ‘Middle class’ was used to signal students whose home and school were located in middle-class suburbs, who had family experience of university, and who were funded by their families. Semi-structured one-on-one interviews were conducted with the 16 students in the first semester of their second year. Interviews allow for a deeper understanding of the social phenomenon being studied than that available through closed-ended questionnaires.[12] Semi-structured interviews consist of a series of questions exploring key areas of a study.[12] The interview for this study probed academic identity and experiences of school-university transition, including academic performance. Eliciting insights from second-year students allowed for their reflection regarding the transition. Their experiences were no longer immediate; yet, the academic performance consequence of these experiences was apparent to them. The interviews were transcribed.

class schools incorporate activities and develop learning strategies that prepare learners for university.[2] Working-class students, who are first in their families to attend university, receive little of this type of preparation.[2] Without having experienced university, their families cannot anticipate the challenges of higher education.[3] Schools with large populations of working-class children seldom provide these learners with information about university, and most rely on teaching strategies that require learner compliance – strategies ill-matched with the requirements for an autonomous university learner.[2] In South Africa, the situation for working-class students is exacerbated by the legacy of apartheid, where schools for such learners continue to be under-resourced, over-crowded, and frequently staffed with under-qualified teachers.[2] Reed’s[5] framework of identity as ‘fastened’, ‘unfastened’ and ‘refastened’ in cultural spaces such as universities was considered appropriate for understanding how students engaged with the expectations of university. The core concepts for analysis were fastened identity (evidence of students’ assumptions about what is required for academic success), unfastened identity (evidence that students recognised the practices required for university success) and refastened identity (evidence that students realised that they had to adopt or incorporate and use new practices so as to be successful). Initial analysis suggested that identity played a significant role in how students engaged with university expectations – with consequences for academic performance. Generally, middle-class students performed well (Table 1). They evinced an identity that recognised the practices required for university success – ‘[It] wasn’t too bad, I could cope – you have to concentrate on work’ [Ghalid]; ‘I have always managed and this is the next step’ [Yasmine]; and ‘That was the only thing – you have to study continuously’ [Antjie]. In contrast, most working-class students struggled academically. Struggling was defined as failing any module or participating in a supplementary or special examination. These students’ university academic identities were less well established. They appeared unaware or unsure of what they needed to do to be successful – ‘I thought I was handling it. But when I got to the exam I wasn’t. It was so easy at school and I thought it would be the same at varsity but it was totally different. It is very upsetting when you work so hard and you see nothing’ [Ronel]. However, identity did not explain the performance of all students. There were middle-class students who struggled academically (Table 1, Group B) and working-class students who performed well (Table 1, Group D). Social class and race – and their associated access to educational resources – fell short of providing a full explanation of academic performance in the transition to university. A further theoretical framework was required to understand the anomalies. Closer scrutiny of the interview transcripts suggested that a theoretical framework which could explain students’ perceptions of their own power over their academic performance had the potential to explain the anomalies. Four concepts of attribution theory were used to analyse the data – internal locus of causality (performance attributed to internal factors such as skills, abilities, efforts), external locus of causality (performance attributed to external factors such as difficult tasks, luck), controllability within (performance perceived to be within an individual’s control, e.g. through personal effort), and controllability without (performance perceived to be outside an individual’s control and attributed to actions of others).

Using the theoretical framework for analysis

Results

Methods

The literature[2,3,13-17] suggests that race and social class are major signifiers in school-university transition and university academic performance. It also highlights that middle-class schools and families prepare young people for university by making overt the practices that are rewarded there.[2] Middle-

Analysis using both frameworks resulted in four groupings within the pilot cohort – academically competent middle-class students, academically struggling middle-class students, academically struggling working-class students, and academically competent working-class students.

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Research

Table 1. Student demographics and academic performance Pseudonym

Social class location

Race location

First-year academic performance

Second-year (first semester) academic performance

Group A (middle-class students who performed well) Ghalid*

Middle class

Indian

Marks between 64% and 90%

Marks between 64% and 77%

Yasmine*

Middle class

Mixed race

Marks between 55% and 74%

Marks between 55% and 83%

Antjie*

Middle class

White

Marks between 50% and 73%

Marks between 55% and 71%

Nadia

Middle class

White

Marks between 64% and 79%

Marks between 66% and 89%

Sandra*

Middle class

White

Marks between 58% and 74%

Marks between 52% and 77%

Sanette*

Middle class

White

Marks between 57% and 82%

Marks between 55% and 75%

Group B (middle-class students who struggled academically) Ibrahim

Middle class

Indian

Marks between 55% and 75%

Marks between 47% and 73% One supplementary examination

Valencia

Middle class

Indian

Failed one module in first semester – transferred to ‘intervention provision’ Passed all intervention modules at end of year

Failed two modules in first semester of second year of registration (i.e. second semester of ‘intervention provision’) – required to leave the programme

Kerusha

Middle class

Indian

Failed one module at the end of first semester – transferred to ‘intervention provision’

Failed two modules in ‘intervention provision’ – required to leave the programme

Group C (working-class students who struggled academically) Ronel

Working class

Mixed race

Marks between 47% and 75% One supplementary examination

Marks between 61% and 75%

Christel

Working class

Mixed race

Marks between 45% and 72% One supplementary examination

Marks between 40% and 62% One supplementary examination

Nelson*

Working class

African

Failed one module in first semester – transferred to ‘intervention provision’ Failed two ‘intervention provision’ modules at year end – required to leave the programme

Registered for oral hygiene – one supplementary examination at end of first semester

Craig*

Working class

Mixed race

Failed one module in first semester – transferred to ‘intervention provision’ Passed all intervention modules at end of year

Passed all modules in ‘intervention provision’ – transferred back to mainstream at end of first semester

Nadia*

Working class

Mixed race

Marks between 48% and 76% One supplementary examination

Marks between 63% and 67%

Group D (working-class students who performed well) Fathima

Working class

Mixed race

Marks between 62% and 77%

Marks between 64% and 85%

Minette

Working class

Mixed race

Marks between 53% and 71%

Marks between 51% and 71%

*Students who participated in the first-year focus-group interviews.

Being middle class and feeling in control

Middle-class students who performed well (Group A: Ghalid, Yasmine, Antjie, Nadia, Sandra, Sanette) came from homes where there was a familiarity with university. They had aspects of university identity embedded

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in their school identity. At school they had learnt the foundational practices that are valued at university. They thus incorporated new practices into their existing fastened academic identities, rather than unfastening their school academic identities. They attributed success to their own efforts, and argued

Research

Table 2. Group A: Middle-class students who feel in control Student

Identity

Attribution

Ghalid

‘At the school that I went to, they drilled it into you that you are going to have a lot of problems and you have to learn how to deal with it. When Human Biology started, that was a shock. We had a high volume of work and you had to learn to cope and plan your day and to study for the tests. But the first year wasn’t too bad. I could cope.’

‘I have the ability. You keep yourself motivated and positive, and then you can cope. It comes down to you as a person. You have got to be strong willed. It is what you make of it.’

Yasmine

‘Some students psyche themselves up, “Oh my word, we have so much work to do.” I just went with it because I knew university was going to be a change. I think the school I went to prepared us for that change. I don’t find it challenging.’

‘It was because of something that was in place, who I am in general. I came with the mindset that I would manage. I have always managed. This is the next step.’

Antjie

‘Maybe it is just what we studied at school or maybe I paid more attention in class. You have to study continuously. The workload over the period of time is just a lot more, not too much, but it is a lot.’

‘I don’t do really well, but I am not going to fail. I have never had that fear of failing. It is not an easy course, but I do have the intelligence to do it.’

Nadia

‘Everyone used to tell me that when you go to university, it’s not like school, no-one will guide you. It wasn’t like that. I managed.’

‘You had to deal with it. I can never leave it and say I am happy if I just make it.’

Sandra

‘It is since I was little I learnt that I had to study hard. The workload was much more than I was used to at school. But the work wasn’t that bad.’

‘My time management is good. I never write tests without studying everything. So I feel good about myself.’

Sanette

‘I learnt at school that if you don’t learn, you won’t get the marks. I managed fine.’

‘I am not worried about it. I am quite good with organising my time. I know that I passed all my subjects.’

Table 3. Group B: Middle-class students who do not feel in control Student

Identity

Attribution

Ibrahim

‘First-year at university is overwhelming. You don’t know where to go for support. You don’t know what to do. Things come from your personal life and pressure. It was a bad luck car. I wasn’t worried about the academics, but I was worried about the car. And then I failed.’

‘I failed the two tests and the exam. The first one everyone failed. I think it is the way they set the papers. They ask you a question and if the answer is not the way they want it, you are not going to get the marks. Sometimes it is out of your control. It makes you feel useless.’

Valencia

‘I think the main issue was leaving home and the fact that my grandmother passed away when I wasn’t there. Everything went downhill from there. It was more emotional and personal.’

The teaching methods – it was up to us rather than the lecturer to teach us. I get completely lost and then I don’t feel like doing it. You are just completely put off and demotivated.’

Kerusha

‘I don’t know why I failed. I didn’t have a problem with the work. I didn’t feel that I lacked working last year because I did put in and it was disappointing that I failed because I don’t go out much. I do my work. So I don’t honestly know why I didn’t make it.’

‘You get into it with one lecturer because they lecture for about a two-week period and then all of a sudden there is a change, and you need to change because they have different teaching styles. The chances of you struggling are quite big. And the lecturer was scary. We were hesitant to go up to him. We weren’t allowed to re-write despite the amount of failures.’

that as they had the prerequisite skills for academic competence, all they had to do was apply effort and use their skills and abilities. Table 2 shows these students’ understandings. The ‘identity’ column indicates identities as fastened, but incorporating practices expected at university. Students’ perceptions of the match between the expectations of university and their own taken-for-granted assumptions about what was required for success at university are shown. The ‘attribution’ column illustrates these students’ sense of inner control and causality.

Being middle class and feeling that things are beyond your control Group B (Ibrahim, Valencia, Kerusha) comprised middle-class students who came from schools and homes that prepared them for university. They should, therefore, have had aspects of university identity embedded in their school identities. There should have been no need for them to unfasten their

school academic identities. In order to ensure academic success they only had to incorporate new practices into their existing identities. However, their testimonies indicated that they were unaware of the prerequisite practices at university, and as they did not recognise them, they did not incorporate them. Instead, their testimony was focused on non-academic challenges. They experienced varying degrees of academic failure. The difference between their accounts and those of Group A students related to attribution. Group B students felt that they lacked control over their academic performance. They assumed an external locus of causality, attributing performance to external factors such as task difficulty or luck. Controllability, for them, was ‘without’. They perceived their performance to be outside their control. They attributed their academic performance to the actions of others. Table 3 shows these students’ understandings. The ‘identity’ column shows their failure to recognise that alternative practices were required

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Research for competence at university. The ‘attribution’ column shows how, as a result of their lack of awareness and consequent discouraging university performance, these students assumed that they lacked control over their performance.

Being working class and feelings that things are beyond your control Without preparation for university,[2] it was unsurprising that the Group C working-class students (Ronel, Christel, Nelson, Craig, Nadia) evinced difficulty making the transition and consequently struggled academically. There was disjuncture between their school academic identities and the expectations at university. There was therefore no possibility for these students to incorporate new practices into their existing academic identities. They were required to unfasten their school identities to build new academic identities. However, in order to do so, they had to recognise the inadequacy of their existing practices and identify suitable practices. There was no evidence that these students did so. Indeed, many of them – despite writing supplementary or special examinations, or even failing modules – argued that they were coping at university. Those who acknowledged that

they were struggling appeared disorientated. This evidence is presented in the ‘identity’ column in Table 4. Unable to explain or understand their academic performance, these students attributed their poor performance to factors beyond their control. These perceptions are indicated in the ‘attribution’ column.

Being working class and feeling in control

The working-class students in Group D (Fathima, Minette) performed well. While it may be argued that they too were not prepared for university,[2] there was evidence that they recognised that different practices were required and what these practices were. They therefore unfastened their school identities and refastened them with ways endorsed at university. This evidence is presented in the ‘identity’ column of Table 5. The refastening of these students’ identities was influenced by the way in which they understood causality and controllability. Both students were clear that success was dependent on personally taking responsibility for practising what they had learnt, thus emphasising their perception of internal locus of control over academic success. These perceptions are presented in the ‘attribution’ column.

Table 4. Working-class students who do not feel in control Student

Identity

Attribution

Ronel

‘I did fail a subject. It was a shock. I thought I was handling it. At school I could study parrot fashion and I thought it would be the same at varsity. When the test comes, it is all those things I didn’t go over.’

‘I could handle the workload but I am not good with calculations and I have a problem with theory. The lecturers should say, “Come and see me about your paper.” That is what they did in high school.’

Christel

‘The course it rather easy. For Clinical Dentistry I actually had a sup for the exam – I think I was studying wrong for that. But I felt okay – nothing was difficult.’

‘This year I had a problem. The class lecturers aren’t nice – strict. I can’t approach them to ask a question.’

Nelson

‘For me, it was just that I am struggling with time management. I know that I am smart. I am doing fine.’

‘Life in residence was not good. Because BA students are making a noise all the time, I wasn’t able to study. I started to fail. Also, Life Sciences – we were about 400. There is a noise with people talking and you can’t hear the important stuff. And, there is this problem with lecturers. They tell you, “No, I can’t do this for you”.’

Craig

‘Last year, it wasn’t as easy as I thought it would be or as fabulous as people make out that university would be. I didn’t really know what is going on and what is important and what I had to concentrate on.’

‘There are certain people like myself who passed the whole year through, but just failed in the exams by 3 or 4%. And then I found out that some people, who didn’t make it, still passed. This girl told me that this guy got a certain percent and he still managed to get a supplementary and to go through to second year.’

Nadia

‘I had quite a few re-writes throughout last year but in the end, actually I got good results, so I was happy with that. I think I am okay.’

‘A lot of us, we have re-writes. I did everything that I thought he wanted and he just gave me zero. I know of someone who got zero and all his information in his answer was right but it just wasn’t in the format that the lecturer wanted. I think it is very unfair. It breaks you.’

Table 5. Working-class students who feel in control Student

Identity

Attribution

Fathima

‘My first year was a big jump. I only got in the 50s in first year. Then I realised I wanted to achieve more and I had to work hard and get better results.’

‘I think that I am a very hard working person and I will go the extra mile and strive to do it. But there were mentors who helped us. I basically learnt how to balance everything.’

Minette

‘The workload was a shock. Everything was different. It was a different way of studying. We had to use logic and understanding.’

‘I definitely know what to do better because Academic Literacy helped me a lot with everything. Now I can’t go out as much as I want to and I always have to say I can’t go out because I have to study now.’

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Research Discussion

This study suggests that students’ academic performance is shaped by social class and race and assumptions of controllability and causality. Social class and race played a significant role in the extent to which students were prepared for higher education. However, social class and race do not provide a comprehensive explanation of academic performance for a significant minority of university students. Irrespective of race or social class, the students who attributed performance to internal factors and perceived the cause of their performance to be within their control were academically more successful. This finding is in keeping with a growing call to investigate the role that human agency plays in social phenomena, such as academic success.[18] It may therefore be argued that decisions regarding student support cannot be based only on assumptions about social class, race, and academic preparation. These factors alone do not explain academic performance. However, race and social class should be taken into account when planning student development.[19] Such interventions may nevertheless fail to assist all students entering university. The study suggests that additional support may be required to help students take personal control over their performance. The need for this support appears to transcend the extent to which a student has been prepared for university. Some students who came from universityorientated backgrounds indicated feelings of powerlessness when discussing their academic competence. Empirical studies argue that attributional retraining (AR) has the potential to change the perceptions of students who attribute performance to causes beyond their control.[7,20] These studies suggest that helping students to change their causal beliefs about factors that affect their academic performance leads to improved performance.[21] Students are assisted to develop a sense of personal control over academic activities and to believe that success is achievable.[22] AR encourages students to attribute poor performance to explanations that imply that failure can be reduced or success can be repeated.[22] Findings from these studies indicate that students who relocate control as internal, perceive effort as a salient explanation for performance and, consequently, experience increased confidence and motivation, and strive for achievement.[7] The AR intervention involves teacher-mediated viewing of a motivational video, talk, interview or drama. These motivations encourage students to adopt controllable explanations of failure, such as insufficient attention or inappropriate study techniques. Motivational input is followed by individual activities intended to consolidate learning from the motivation. Effective follow-up activities include providing students with key point summaries, opportunities to put learning from the motivation into practice, requiring students to practise thinking from an internal causality perspective (such as recording as many reasons as possible for why their grades should improve), and reflective activities (such as writing and discussing what they perceive to be important aspects of the AR session).[7,21,22] To be effective, AR interventions require a consolidation activity in which students apply or reflect on what they have learnt.[7] The provision of support in the form of AR is not unproblematic, especially in an SA context, where the barriers to learning in higher education are overwhelming.[23] AR alone should not be expected to engender the belief that success is achievable, as students from backgrounds not able to prepare them for university might fail, and blame ‘lack of effort’ for that failure. However, integrating AR into academic support programmes

offers a mechanism for helping students to reflect on their learning and the strategies they adopt when learning. Motivational input would allow them to recognise their enormous potential – how, even in the face of adverse academic preparation, they have been selected for university because they have already demonstrated their potential to succeed. Framing academic support activities as providing the tools to turn potential into academic competence provides further motivation. Such an approach acknowledges both students’ real disadvantages and their potential to develop competence in areas of initial limitation. Combining academic support activities with AR goes some way to providing first-generation university students with the kind of insider information that middle-class students bring to university. Such AR would make explicit what competencies (such as time management, independent note-taking, reading and writing extended text) are required in order to be successful at university, would support students in the development of these competencies, and would provide students with opportunities to reflect on and critically evaluate their use of these competencies. For middle-class students, AR may have benefits when introduced as suggested in the literature – as a mechanism that encourages students to attribute poor performance to explanations that imply that failure can be reduced or success repeated.[22] Through reflection on academic performance and associated academic practices, these students might be taught to recognise the contributory factors (e.g. time management or concept mastery) to academic performance. Successful strategies can then be repeated and appropriate ones for addressing shortcomings taught, practised and evaluated – thus facilitating the development of an explanation of academic performance within the control of the student.

Conclusion

This study drew on the voices of second-year dentistry students and the theoretical tools of academic identity and attribution theory to understand the relationship between transition to university and initial academic performance. Race and social class and perceptions of control were found to play a role in students’ academic performance. Suggestions from the literature regarding AR were adapted to propose ways to assist students towards competent academic performance. The limitations of this study should, however, be taken into account when considering the wider applicability of the findings. This was a smallscale pilot study. However, the rich data that are accumulated from such studies allow for the highlighting of salient issues for further investigation.[9] Larger-scale qualitative studies are required to confirm the validity of the findings from this pilot study. Quantitative questionnaire-based studies, designed from the findings of larger qualitative studies, would allow for the survey of substantial numbers of students and further validation of the findings. Ultimately, a diagnostic tool might be developed to allow academically struggling students to identify how their academic practices contribute to their academic performance. Academic support activities could then be developed to assist students to become more academically competent. By using the diagnostic tool and participating in support activities students will have opportunities to perceive their academic development and their academic performance as within their control. Acknowledgements. I would like to thank all the students who took part in the research, willingly sacrificed their time and shared their experiences of transition to university.

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Research References 1. Scalon L, Rowling L, Weber Z. ‘You don’t have like an identity … you are just lost in a crowd.’ Forming a student identity in the first-year transition to university. Journal of Youth Studies 2007;10(2):223-241. 2. McMillan W. Understanding diversity as a framework for improving student throughput. Education for Health 2007;20:71. http://www.educationforhealth.net/ (accessed 23 October 2013). 3. McMillan W. ‘They have different information about what is going on’: Emotion in the transition to university. Higher Education Research and Development 2014;33:1123-1135. 4. Wendt A. Anarchy is what states make of it. International Organization 1992;46:391-426. 5. Reed G. Fastening and unfastening identities: Negotiating identity in Hawaii. Discourse: Studies in the cultural politics of education 2001;22(3):327-339. 6. Weiner B. Attribution theory in organizational behaviour: A relationship of mutual benefit. In: Martinko M, Weiner B, Lords R, eds. Attribution Theory: An Organisational Perspective. Boca Raton: CRC Press, 1995:3-6. 7. Perry R, Hall N, Ruthig J. Perceived (academic) control and scholastic attainment in higher education. Higher Education Handbook of Theory and Research 2005;16(1):837-851. 8. McMillan W. Finding a method to analyse qualitative data: Using a study of conceptual learning. J Dent Educ 2009;73:53-64. 9. Thabane L, Ma J, Chu R, et al. A tutorial on pilot studies: The what, why and how. BMC Med Res Methodol 2010;10:1. [http://dx.doi.org/10.1186/1471-2288-10-1] 10. Calder J. Survey research methods. Med Educ 1998;32:636-652. 11. Bertelsmann Stiftung. South African Country Report. Gutersloh, Germany: Bertelsmann Stiftung, 2012. www. bti-project.org/uploads/tx_itao.../BTI_2012_South_Africa.pdf (accessed 27 January 2014). 12. Silverman D. Doing Qualitative Research. London: Sage, 2000. 13. Li D. They need help: Transfer students from four-year to four-year institutions. The Review of Higher Education 2010;33(2):207-238.

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14. Pugh G, Coates G, Adnett N. Performance indicators and widening participation in UK higher education. Higher Education Quarterly 2005;59(1):19-39. 15. Reay D, David M, Ball S. Degrees of choice: Class, race, gender and higher education. Staffordshire, UK: Trentham Books, 2005. 16. Reay D. Exclusivity, exclusion, and social class in urban education markets in the United Kingdom. Urban Education 2004;39(5):537-560. 17. Reay D. Class, authenticity and the transition to higher education for mature students. The Sociological Review 2002;50(3):398-418. 18. Archer M. The Reflexive Imperative in Late Modernity. Cambridge: University Press, 2012. 19. Sikakana C. Supporting student-doctors from under-resourced educational backgrounds: An academic development programme. Med Educ 2010; 4:917-925. 20. Wilson T, Damiani M, Shelton N. Improving the academic performance of college students with brief attributional interventions. In: Aronson J, ed. Improving Academic Achievement: Impact of Psychological Factors on Education. San Diego, CA: Academic Press, 2002:88-108. 21. Perry R, Hechter F, Menec V, et al. Enhancing achievement motivation and performance in college students: An attribution retraining perspective. Research in Higher Education 1993;34:687-723. 22. Perry R. Perceived (academic) control and causal thinking in achievement settings. Canadian Psychology/ Psycholigue Canadienne 2001; 4(4):312-331. 23. Ndebele N, Badsha N, Figali B, Gevers W, Pityana B, Scott I. A proposal for undergraduate curriculum reform in South Africa: The case for a flexible curriculum structure. Report of the Task Team on Undergraduate Curriculum Structure. Discussion document. Pretoria: CHE, 2013.

Research The Human Rights Key: An innovative tool for teaching health and human rights in the health sciences V A Mitchell, BSc (Physio), MPhil (HES) Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: V A Mitchell (veronicaannmitchell@gmail.com)

Background. In response to the need for health and human rights education in undergraduate medical curricula, the Faculty of Health Sciences at the University of Cape Town, South Africa, has included human rights learning in its reformed programme. Drawing on experiences in several curricular initiatives within the Faculty and beyond, I introduce the Human Rights Key as a new heuristic learning tool. Objective. To share a teaching innovation in an area of need in medical education. Method. The Key scaffolds and facilitates students’ learning through a sequential process of guided self-reflection with probing questions. It illuminates the inter-relationship of key human rights concepts, enabling students to create and make connections between human rights principles, legal mechanisms, their own personal realities and their developing clinical practice. Discussion. Feedback reflects the effectiveness of the Human Rights Key in supporting transformative learning, suggesting that the Key will remain prominent in students’ memory. Online publication of the Key as an open educational resource (OER), with extensions to specific themes, has increased its impact and demonstrated the generalisability of the tool. Conclusion. I propose the Human Rights Key as a useful visual communication tool to guide students in connecting their classroom learning with the reality of local, regional and international health and human rights issues. As an OER with a Creative Commons licence, the Key is available online for both educators and students to use as a resource with downloadable components. Afr J Health Professions Educ 2015;7(1):39-42. DOI:10.7196/AJHPE.366

‘Health workers need to be educated about how to incorporate human-rights principles into their work.’[1] While teaching human rights to a diverse group of health science students, I felt a need to open a door to turn learning into personal meaning-making beyond the understanding of legal instruments. This shift in teaching objectives, from transmission of knowledge towards transforming attitudes, created an opportunity to try new and alternative approaches that could promote the personal connections needed to motivate individual students to engage in issues of social justice. Human rights are defined by London and Baldwin-Ragaven[2] as ‘universally applicable social or material entitlements, essential to fulfil fundamental needs, which individuals can claim from society on the basis of [their] humanity’. Mann[3] argued for the inextricable link between human rights and health to be recognised beyond the health consequences of human rights violations. This broader perspective takes into account the multiple influences that impact on human rights and health, including the promotion and protection of human rights towards human flourishing. London et al.[4] point out that health professionals can be change agents to advance social justice and equity in health; yet, they can also create barriers when they act as gatekeepers who limit access to health. In South Africa (SA), a progressive constitution sets norms and standards within a legal framework towards achieving democratic practices; yet, the legacy of apartheid, with growing inequalities and a weak public health system, challenges educators in a health science faculty (HSF) to seek ways to promote students’ social responsiveness towards social justice and equity. A history of complicity by health professionals in human rights abuses is a contributing factor that is driving curricular change.[5] The

Health Professions Council of SA (Committee on Human Rights, Ethics and Professional Practice 2006) mandated for human rights (together with professional ethics and medical law) to form a core component of medical undergraduate curricula. In the HSF at the University of Cape Town (UCT) a transformation agenda intends to scaffold human rights as a curricular golden thread throughout the years of undergraduate study. To understand health through a human rights lens it is important to recognise the social, political, cultural and economic factors that contribute towards or limit wellbeing. Apart from the structural factors in the health system there are many actors, including medical undergraduate students, who can play a role in mediating the realisation of the rights of others. Human rights education (HRE) enables the use of critical self-reflection as a process of self-discovery. It fosters a consciousness for each student to acknowledge the realities of difference, and the relationships between the determinants of health, the multiple stakeholders and influences, and the legal instruments. Although HRE forms part of the life orientation course in SA high school curricula, few students appear to understand the relationship between classroom learning and clinical practice, as is apparent in student feedback. To view health through a multifaceted lens, I propose an ontological approach to teaching, one in which ‘knowing is … situated within a personal, social, historical and cultural setting … a way of thinking, making and acting’.[6 ] In this article I explain the emergence of the Human Rights Key (Key) as a tool to equip students and educators to learn and teach human rights issues in an engaging manner. I explain the meanings to be drawn from the metaphor and describe how the Key is used in the classroom. It has also been made available as an open educational resource (OER) and shared with the wider educational community. The limitations and transferability of the

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Research Key are explored, including the expansion of its usability through the new opportunities afforded by the internet, leading to my conclusion.

Emergence of the Key

Beyond the school curriculum, the first year of the reformed UCT curriculum in the HSF includes a course ‘Becoming a professional’ (BP) – 25% of its content is related to health and human rights. The overriding theme in this multidisciplinary module is the ‘Integrated health professional’ (IHP), a model of professional identity constituting the reflective, empathetic and knowledgeable domains.[7] As a facilitator in this course, I felt challenged in engaging students’ interest and commitment to human rights. I wanted to assist them to link their present being to their future practice and to the codified legal human rights instruments. While teaching senior students in their third year, opportunities arose to explore additional ways to promote human rights learning. As I initiated and facilitated human rights workshops in the Department of Obstetrics and Gynaecology, a wheel image became a useful visual model, using the IHP concept from BP as the hub. Concentric circles indicated progressively broader influences from the family, community (local) and country (national) to wider international actors. The Universal Declaration of Human Rights created the foundation or holding platform (Fig. 1). Further examination of possibilities led me to develop the wheel into the head of a key. The Key was recognised as a symbol for opening and closing doors – as a self-assessed indicator measuring and evaluating students’ own agency. This heuristic Key offered a visual model for students to draw on their prior learning and personal experiences. Students are able to reflect on their own biographies and frames of reference, shifting from global to closer domestic influences. Because of SA’s discriminatory history, many of our students’ lives have been and still are affected by past and present injustices. Through the Key, each student may recognise the multidimensional aspect of human rights and its relationship with multifaceted developing professionalism.

Method

Cutting the Key

In the classroom I construct the Key (Fig. 2) piece by piece, using paper templates, guiding students to place their own content into the visual model. Probing questions to promote the students’ understanding of health and human rights facilitate their reflection on the state of their own Keys within

Wheel for human rights education Global Context National Local

IHP

K Legal instruments

National constitution International conventions

Universal Declaration of Human Rights

Fig. 1. Health and human rights wheel (IHP = integrated health professional; R = reflection; E = empathy; K = knowledge).

Global community Country Local community family MEDIA

efle

n ctio

Obstacles

pa thy

Education and awareness Knowledge

Non-governmental organisations

Fig. 2. The Human Rights Key infographic (by Veronica Mitchell, UCT, 2011).

Universal Declaration of Human Rights (UDHR)

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International Covenant of Economic, Social and Cultural Rights (ICESCR)

Convention on the Rights of the child

C R C

International Covenant of Civil and Political Rights (ICCPR)

Convention on the Rights of Persons with Disabilities

Convention on the Elimination of All Forms of Discrimination Against Women

C E D A W

C R P D

C O N S T I T U T I O N

Research a human rights framework, resulting in raising their self-awareness and evolving consciousness. By posing problems related to their future practice as clinicians working within varying spheres of influence in the context of women’s health, students gain a deeper understanding of the complexities of the lived realities of individuals and population groups. A detailed explanation of the Key’s components and the method used to facilitate student learning is available on the Human Rights Key website (https://open.uct.ac.za/handle/11427/6599).

Testing the Key

Feedback from both educators and students has indicated the meaningful contribution that the infographic offers to HRE. Since its inception in 2008, it has been used in the classroom, with educators from/at other institutions, and presented at both local and international conferences. The Key’s visual representation is appealing to students, assisting them to remember the concepts of what they have learnt as well as showing how the many components are integrated. The Key provides a summary of previous discussions and learning within the larger context of local and international influences. It illuminates the inter-connectiveness of the elements, demonstrating the enormous value of education and awareness. Furthermore, from an educator’s point of view, the Key enlightened the students’ understanding by simplifying concepts and clarifying their relevance and relationships by contextualising the complexities. The transformative objective in HRE is facilitated by the Key, providing a vehicle to value different standpoints. As a tool for critical reflection, it gives students an opportunity to explore their own areas of need. Moreover, the model enables students to identify their future professional responsibilities. However, a few students have found the Key challenging and confusing. Responding to students’ earlier calls for more structure, the method of delivery in presenting the Key has changed. Initially, I drew the model on a white board, but now I use coloured templates to represent the Key’s components to show how they fit together, and refer students to the website for further self-study. The addition of the Key as an online resource makes it available to students to revise and reinforce their learning. Research is planned into the longitudinal impact of the Key on students’ social responsiveness, with an examination of the difficulties that appear to limit a few students’ understanding of the concepts.

Discussion

Interpretation of the Key

The Key contributes to substantive understanding of human rights. It offers a visual tool to explore and challenge values and attitudes that ‘truly reflect the underlying principles of human rights: universality, indivisibility, interdependence, equality, human dignity, respect, non-discrimination and social progress’[8] – essential components for the success of HRE. Turning human rights into personal realities is facilitated by means of the Key’s symbolic significance and its individualistic design for each person. A connection between students’ personal experiences and their future professional practice is created. As Haidet et al.[9] indicate in their study using life-circle drawings, a visual diagram can be useful in understanding how the webs of relationships in the life-worlds of students may shape and influence their practice. The Key metaphor enables ‘us with the capacity as agents to make sense of the universe, sort out perceptions, make evaluations, create an adventure in meaning and guide our purposes’.[10] Deshler emphasises

the relevance of metaphors for transformative learning,[10] particularly in participatory teaching as a vehicle to promote dialogue and the recognition of new, unexplored perspectives. He argues that metaphors offer a sense of ownership, freedom and liberation, and assist learners to recognise unexamined influences that impact on their lives. Generally, keys are personal possessions kept and cared for in a vigilant manner with a sense of responsibility. As Key holders and duty bearers, the quality of practitioners’ Keys can reflect their own agency. For instance, indifference and complacency imply a Key sitting in a lock without being turned. Similarly, conformity and acceptance of a status quo could mean a Key that is never or seldom used. Even when mechanisms are in place, initiative, knowledge, skills and confidence are needed to take up the Keys and use them in a meaningful manner. To empower others out of their vulnerability, doctors as agents of change have the opportunity to become champions of equality. London[11] argues that agency is critical to a human rights approach. Health professionals, through their position of authority and as community role models, can assist others in finding and turning their Keys, acting as mentors in their advocacy roles and more conventional role of monitors. As students gain a critical understanding of their individual human rights values through guided personal reflection in constructing their own Keys, an opportunity is created to generate personal and social change. For many marginalised people, their Keys can be interpreted as blanks – present, yet indistinct – not fulfilling their purpose of opening doors. In ongoing human rights violations the Key can play a protective role in turning against abuse, unlocking the doors to alternative choices or locking doors to oppressive situations. Doors tend to be bolted through oppression and ignorance. In such situations, assistance may be needed to unlock potential individual opportunities. Developing partnerships with co-operative efforts are key to a human rights approach in health.[12] If health professionals facilitate the opening of channels of communication, the Keys held by communities are ‘oiled’ – as with the locks they are used in – which would allow them to be used more easily and freely. Such a supportive bridging role is evident in the relationships developed with government, including social services and the local police, and civil society organisations, such as community-based organisations, non-governmental organisations and faith-based groups. Networking and collaboration create avenues for support and assistance in promoting fairness in a united democracy. The expansion of the initial classroom Key has led to the development of the Key website on UCT OpenContent. Expanding themes include the rights of persons with disabilities (Disability Key) and sexual and gender minorities (lesbian, gay, bisexual, transgender (LGBT) Key), demonstrating the generalisability of the model. As an OER it gives permission through a Creative Commons licence (Attribution – Non-Commercial – ShareAlike) for others to use, download and adapt for their own context. Alongside the barriers to realising rights, is the recognition that when health professionals become human rights defenders, holding both their own Keys and those of others, they can become vulnerable. Their actions and decisions may be influenced by third parties.[13] In such situations of dual loyalty, value judgements need to be made – knowing which Key to hold and how far to turn it.

Further plans for the Key

As indicated earlier, research is needed to assess the long-term impact of the Key model on individual students’ learning and professional practice.

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Research It will be useful to explore the transformative impact in changing attitudes and collective behaviours towards defending and promoting human rights. Furthermore, the Key may act as a valuable tool to stimulate institutional discourse and help to build connections between different stakeholders.

Conclusion

In this article I have described the development of an innovative Key model for teaching health and human rights. The visual representation reflecting the principles of HRE illustrates the inter-relationship between professionalism and legal mechanisms, assisting students in guiding their understanding and personal interpretation of the multidimensional nature of health and human rights. Furthermore, the visual medium helps students to self-reflect within their own contexts and experiences, interpreting the broader dynamic of social, cultural, economic and political influences. Students gain insight by examining and analysing the components of their own Keys. By raising awareness of human rights for individuals and communities, students as future health professionals are able to draw on this reflective tool. In so doing, they may contribute towards the progressive realisation that everyone has the right to the highest attainable standard of health. Healthcare through a human rights lens acknowledges and respects varying perspectives. The internet offers new opportunities to strengthen HRE. By publishing the Key as an OER on UCT OpenContent, with additional theme topics, it can be used by others beyond one institutional boundary. The increasing views on the website indicate the ongoing interest and value of sharing classroom innovations. Unlocking a toolbox of opportunities, the Key promotes deep learning, advancing respect for social justice and equity. International, regional and

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local human rights mechanisms provide the strength and support for each individual’s Key – a universal entitlement. Acknowledgements. I wish to thank Prof. Leslie London, Dr Kevin Williams, Prof. Wendy McMillan, Prof. Athol Kent, Mr James Irlam, Mr Gregory Doyle and Dr Claire Mitchell for their inspiration and support in assisting my development of the Human Rights Key. In addition, I thank and acknowledge Mrs Denise Oldham and volunteers at UCT’s Disability Unit.

References 1. Gruskin S, Mills E, Tarantola M. History, principles and practice of health and human rights. Lancet 2007;370(9585):449-455. [http://dx.doi.org/10.1016/S0140-6736(07)61200-8] 2. London L, Baldwin-Ragaven L. Human rights obligations in health care. Continuing Medical Education 2006;24(1):20-24. 3. Mann J. Medicine and public health, ethics and human rights. In: Mann JM, Gruskin S, Grodin MA, Annas GJ, eds. Health and Human Rights. A Reader. New York: Routledge, 1999:439-452. 4. London L, Fick N, Tram KH, Stuttaford M. Filling the gap: A learning network for health and human rights in the Western Cape, South Africa. 2012. http://www.hhrjournal.org/2013/08/19/filling-the-gap-a-learning-networkfor-health-and-human-rights-in-the-western-cape-south-africa/ (accessed 12 January 2015). 5. Baldwin-Ragaven L, De Gruchy J, London L. An Ambulance of the Wrong Colour. Health Professionals, Human Rights and Ethics in South Africa. Rondebosch: University of Cape Town Press, 2009. 6. Dall’Alba G, Barnacle R. An ontological turn for higher education. Studies in Higher Education 2007;32(6):679-691. [http://dx.doi.org/10.1080/03075070701685130] 7. Olckers L, Gibbs T, Duncan M. Developing health science students into integrated professionals: A practical tool for learning. BMC Med Educ 2007;7:45. http://www.biomedcentral.com/content/pdf/1472-6920-7-45.pdf (accessed 12 January 2015). 8. Nazzari V, Mc Adams P, Roy D. Using transformative learning as a model for human rights education: A case study of the Canadian Human Rights Foundation’s International Human Rights Training Program. Intercult Educ 2005;16(2):171-186. [http://dx.doi.org/10.1080/14675980500133614] 9. Haidet P, Hatem DS, Fecile ML, et al. The role of relationships in the professional formation of physicians: Case report and illustration of an elicitation technique. Patient Educ Couns 2008;72:382-387. 10. Deshler D. Metaphor analysis: Exorcising social ghosts. In: Mezirow J and Associates. Fostering Critical Reflection in Adulthood. San Francisco, Calif.: Jossey-Bass, 1990: 296-313. 11. London L. What is a human-rights based approach to health and does it matter? Health Hum Rights 2008;10:1. 12. London L. Can human rights serve as a tool for equity? 2003. http://www.equinetafrica.org/bibl/docs/ POL14rights.pdf (accessed 14 January 2015). 13. Rubenstein L, London L, Baldwin-Ragaven L. Dual loyalty and human rights in health professional practice: Proposed guidelines and institutional mechanisms. 2003. https://s3.amazonaws.com/PHR_Reports/dualloyalties2002-report.pdf (accessed 14 January 2015).

Research Discovering the value of personality types in communication training for pharmacy students M J Eksteen, BPharm, MPharm; M J Basson, BSc HED Hons, BSc, MSc Department of Pharmacy Practice, School of Pharmacy, Faculty of Health Sciences, Potchefstroom Campus, North-West University, Potchefstroom, South Africa Corresponding author: M J Basson (marietta.basson@nwu.ac.za)

Background. The current movement in the pharmacy profession, from the product towards the patient, demands new educational approaches that support the exit-level outcomes of the South African Pharmacy Council as implemented in 2013. Patient-centred communication calls for an ability to ‘walk in the patients’ shoes’. Pharmacists, like others, are naturally inclined to think and treat others as they themselves perceive the world, which can result in miscommunication. Objectives. To determine the prevalence of the 16 different Myers-Briggs Type Indicator (MBTI ) communication styles, and compare them with the prevalence of these styles in the South African (SA) population. Furthermore, to determine the possibility of a pharmacy student interacting with a patient with a similar communication style. Method. A novel way to sensitise pharmacists to the differences in people’s experiences, behaviours and communication styles is to introduce them to type theory with the MBTI . A survey design was used to determine 786 pharmacy students’ communication styles, using the MBTI . These students were enrolled for the subject ‘Communication for pharmacists’ at the largest pharmacy school in SA. Results. More students were consistently found with Sensing Feeling preferences than in the general SA population. The possibility that a pharmacy student might consult with a patient with a similar style varied between one and 414 chances out of 10 000 consultations. Conclusion. This study highlights the importance and possibility of using the MBTI as part of communication training of pharmacy students. Sensitising students to their own preferences and those of their patients empowers them to patient-centred communication.

Afr J Health Professions Educ 2015;7(1):43-46. DOI:10.7196/AJHPE.370

Patient-centredness requires pharmacists to view their patients as individuals with unique experiences.[1] Each patient in their social context responds uniquely to verbal communication. Traditionally, pharmacists have been regarded as dispensers of prescription medication.[2] They were trained to understand medication, focus on the product and give product information as the main approach to patients, and emphasise medication adherence as a goal. The move in the profession from product orientation (dispensing medication) to patient orientation requires expanding of their professional training.[3] The pharmacist’s professional role has matured to include provision of information, education, and pharmaceutical care services. This expanded role encapsulates a collaborative pharmacist-patient relationship in which both have roles and responsibilities.[4] To be patient-centred, pharmacists need to learn new ways of being with their patients and talking to them, which involves new knowledge and skills as well as innovative ideas to advance the profession towards this role. Communication is mentioned in six of the 10 Competence Standards identified by the South African Pharmacy Council, which together form the minimum requirements for an entry-level pharmacist to be registered in South Africa (SA).[5] Developed communication skills are essential for the practising pharmacist and non-negotiable in building provider-patient relationships. Effective communication is at the heart of patient safety and optimal health outcomes.[6] Training pharmacists to be more aware of the impact of their natural communication style on their patients[7] and healthcare colleagues empowers them to move their professional role from product to patient focused. Such awareness may prompt pharmacists to develop their interpersonal skills to address the human-centred elements of patient-centredness. The more advanced the communication skills of a pharmacist, the better he is equipped to assist patients.[8]

Personality type is an indicator of communication style and the MyersBriggs Type Indicator (MBTI ) is an instrument based on the work of Carl Jung. According to the personality type framework, two people of the same type have the least chance of miscommunication. Consider the four bipolar preference pairs[9] of the MBTI : • Extroversion (E) and Introversion (I). A focus on and energy from the outer world of people and activity v. a preference for an inner world of thoughts and feelings. • Sensing (S) and Intuition (N). A practical focus on facts and detail v. attention to patterns and possibilities. • Thinking (T) and Feeling (F). A focus on logic and analysis v. personal values and priorities. • Judging (J) and Perceiving (P). A tendency for decisiveness and preference for structure and control v. a tendency to keep options open and a preference for spontaneity and flexibility.

A person is naturally inclined to prefer one of the preferences in each pair, which is usually better developed. This choice gives rise to a preference combination or personality type. The 16 personality type combinations are each associated with habitual preferences and behaviours. The MBTI is normally used in education to develop teaching methods that will meet the needs of the different types and to understand differences in motivation for learning. In communication training, the MBTI is regularly applied to learn approaches that are most likely to lead to agreement and co-operation, increase understanding by ‘talking the language’ of different types, and create a climate where differences are seen as valuable.[9] For the first time in pharmacy education, personality types were used as a non-judgemental tool that offers a framework to sensitise pharmacy

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Research students to their own communication style preference and its effect on their patients.[9] Using the MBTI as part of the communication training of pharmacy students gives them the opportunity to appreciate and understand the differences between them as professionals and them and their patients. In this project, the MBTI was included in the training of pharmacists to empower them on their way to patient-centred care. More importantly, over the long term, pharmacy students will form better relationships with their patients, which in turn will result in improved medication adherence rates. This study identified the prevalence of the different communication styles among pharmacy students and determined the possibility of their interacting with a patient with a similar communication style.

Method

This study is part of a larger project on teaching communication to pharmacy students. All students at a higher education training institution in SA, who enrolled from 2007 to 2012 for the semester subject ‘Communication for pharmacists’, were part of the study population. As part of their training, they took the MBTI under supervision of a registered user.[9] The results were verified through workshops where students experienced the communication implications of their preferences in their future line of work. They also became aware of the implications of communication preferences other than their own. A survey design was used in this study. The information was collected for each group at the beginning of the semester subject and is used here to describe the study population at that single point in time. Form G of the MBTI , a paper and pencil Jungian-based inventory, was used as the measuring instrument. It consists of 126 items that measure the four bipolar preference pairs. Descriptive statistics were used to describe the fourth-year students of 2007 - 2012 and compare them with the SA population in terms of the four bipolar preference pairs. In 2012, owing to a curriculum change, the communication course moved from the fourth to the third year and we had an opportunity to evaluate both year groups in one year. The third-year students (2012) were described and compared with the fourth-year students in the same year to establish whether the same pattern holds. Finally, the probability that a pharmacy student will interact with a patient of a similar preference type, was calculated for the fourth-year students from 2007 to 2012 and the third-year students of 2012. To calculate the probability for equally likely outcomes, the probability (p) that an event occurs equals the number of favourable events divided by the number of possible events. For independent events, the probability that both events will happen equals p (event A) multiplied by p (event B).[10] The MBTI was used primarily as a teaching tool and the data for this project were analysed long after the students completed ‘Communication for pharmacists’. The students’ names and numbers did not form part of the data analysed; therefore, no individual could be identified or implicated in the summary analysis. The project was executed by a registered MBTI user, especially the data collection and the verification of the results with the participants. The scope of this study was limited to the preferences of pharmacy students at a single pharmacy school in SA – the largest pharmacy school in the country[11] – and could form the basis for a broader, national research project from which it would be possible to generalise findings.

Results and discussion

In SA, the pharmacy profession is currently dominated by women[11] and our study population (N=786) reflected this trend. Of the 201 thirdyear students in 2012, 45 (22.4%) were male, and of the 585 fourth-year students between 2007 and 2012, 151 (25.8%) were male.

MBTI preference distribution of fourth-year students from 2007 to 2012 When we observed the individual preferences of the fourth-year students, it was found that there were significantly more who preferred Introversion, Sensing, Feeling and Judging than in the general SA population (Fig. 1).[12] This indicated that the proportion of students with a preference for Feeling in the study population varied between 41% and 58%,[6] i.e. at least 12% above the 28.3% reported in the SA population.[12] There was a consistent over-representation of students with a preference for Feeling compared with the general population.

MBTI preference distribution of third- and fourth-year students in 2012 When comparing the preference distribution of the third-year students with that of the fourth-year students (Fig. 2), it was found that the preference distribution of the former followed the same pattern as that of the fourth-year students in 2012. Both groups of 2012 students had preferences for Introversion, Sensing, Feeling and Judging compared with the general population in SA. These findings corroborate the analysis of the fourth-year students (2007 - 2012) 90 80 70 60 50 % 40 30 20 10 0

E I S N T F J P 2007 - 2012 Fourth-year students 50.3 49.7 79 21 51.8 48.2 70.4 29.6 South African population 55.0 45.0 67.9 32.1 71.7 28.3 65.1 34.9 Preferences

Fig. 1. Preference distribution for fourth-year students between 2007 and 2012 compared with that in the SA population.[12] (E = Extroversion; F = Feeling; I = Introversion; J = Judging; N = Intuition; P = Perceiving; S = Sensing; T = Thinking.) 90 80 70 60 50 % 40 30 20 10 0

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2012 Third-year students 2012 Fourth-year students

E I 49.3 50.7

S N T 81.6 18.4 55.7

F 44.3

J P 72.1 27.9

45.4 54.6

83.1 16.9 49.2 50.8

74.6 25.4

Preferences

Fig. 2. Preference distribution for third-year students of 2012 compared with that of fourth-year students of 2012. (E = Extroversion; F = Feeling; I = Introversion; J = Judging; N = Intuition; P = Perceiving; S = Sensing; T = Thinking.)

Research

25 20 %

15 10 5 0

ISTJ 20.9 2007 - 2012 Fourth-year students 17.8 South African population 19.8 2012 Third-year students

ISFJ 15.9 16.0 5.5

INFJ INTJ ISTP ISFP INFP INTP ESTP 1.9 1.0 4.5 4.5 1.9 0.4 6.5 2.7 1.4 3.9 3.6 2.4 2.2 5.5 1.7 3.9 4.7 2.5 2.7 4.2 5.9

ESFP ENFP ENTP 3.5 4.0 2.5 5.0 3.9 3.1 6.4 3.5 2.2

ESTJ ESFJ ENFJ ENTJ 17.0 9.0 3.5 3.0 15.4 11.8 2.9 2.4 20.8 5.2 5.0 6.0

Personality type Fig. 3. The MBTI® personality type distribution of the 2007 - 2012 fourth-year and 2012 third-year study population compared with the SA population.[12] (E = Extroversion; F = Feeling; I = Introversion; J = Judging; N = Intuition; P = Perceiving; S = Sensing; T = Thinking.)

Probability (%)

overall. The findings showed that there are consistently more students per year group with a preference for Sensing and/or Feeling in the study population compared with the general population since 2007.[7]

MBTI personality type distribution

The MBTI types most strongly represented in the 2007 - 2012 study population were ISTJ, ISFJ, ESTJ and ESFJ. Compared with the general population, it is clear that there were more ISFJs and ESFJs in the study population (Fig. 3). In the SA population the least represented type is INFJ,[12] among the 2012 third-year students it is INTP, and among the 2007 - 2012 fourth-year students it is INTJ.

Probability that a like-minded student and patient will interact Probability was calculated using the values in Fig. 3. A fourth-year student with the greatest possibility of interacting with a like-minded patient is an ISTJ personality type (Fig. 4). Therefore, out of 10 000 consultations that the ISTJ fourth-year student will conduct, only 352 are likely to be with an ISTJ patient. Participants who have the smallest chance (0.01%) to interact with a patient of similar type are third-year INTP students in 2012, i.e. of 10 000 consultations that the student will conduct, only one might be with a patient with an INTP preference. The same pattern held for the entire fourth-year population over the six years and for the 2012 cohort of third-year students. The likelihood of pharmacy students interacting with patients with

4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00

2007 - 2012 Fourth-year students

ISTJ 3.52

2012 Third-year students

4.14

ISFJ 0.88 0.87

ESTJ 3.20

ESFJ 0.61

3.54

0.47

Personality type

Fig. 4. The four personality types in the study population with the greatest possibility to interact with like-minded patients in SA. (E = Extroversion; F = Feeling; I = Introversion; J = Judging; N = Intuition; P = Perceiving; S = Sensing; T = Thinking.)

similar preferences varies between one and 414 chances in 10 000, emphasising the importance for a pharmacy student to be aware not only of his own communication style or preferences, but also of the expectations that patients with other styles are likely to have of pharmacists in a professional setting.

Discussion

For the first time in the communication training of pharmacy students at a higher education training institution, the personality type framework of Myers and Briggs was used to enable students to appreciate their own preferences and communication styles and those of others.[9] During the first part of this project, it was shown that the MBTI personality theory holds for pharmacy students,[7] even though they have been trained in a health environment. Prompted by questions related to their professional practice,

the students still responded habitually according to MBTI theory. The entire study population, irrespective of year of study, favoured the Sensing-Feeling preferences. Compared with the SA population, it seems that a greater proportion of students at this pharmacy school tends to have SensingFeeling preferences, with the accompanying communication style implications.[13] Patients with a preference for Sensing might prefer to focus on detail and facts during communication, are anchored in current realities and common sense, and immediately apply what is communicated. However, patients with a preference for Intuition might talk about possibilities and trends, are future orientated and may prefer to link and integrate information,[13] e.g. students with a preference for Sensing who may focus on facts and details[7] have to realise

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Research that some patients with a preference for Intuition may be interested in alternatives in a medication-related request. It was established that there were consistently more students with a preference for Feeling than in the general population, which has positive implications for patient-centred care. Patient-centred care requires the pharmacist to be able to strengthen the relationship with the patient, improve the patient’s knowledge about health, promote communication about important health-related matters and engage the patient to become involved in his own healthcare.[14] Pharmacy students with a preference for Feeling may have a natural tendency to empathise and develop rapport with their patients; appreciate their patients’ perspective; be supportive, nurturing and interested in their patients; and enjoy collaborating.[13] Therefore, students with a preference for Feeling may be naturally orientated towards patient-centred care. Such students need to realise that patients with a preference for Thinking might, for example, prefer objective, honest and frank feedback. These patients might prefer to debate and challenge medication information and request the pharmacist to list the pros and cons.[13] In conclusion, even an ISTJ student among the fourth-year cohort, with the best chance of consulting with a like-minded patient, will not be attending to a patient with a similar personality type for 96.48% of the time. While some patients experience a specific behaviour as caring, others might experience it as non-caring.[15] It seems that central to the patient’s experience of patient-centred care is a set of pharmacist abilities, including seeing the patient’s point of view. A pharmacist who is familiar with personality type theory has a better chance to understand a patient’s experience. Pharmacists do not need to know the personality type of each patient; they only need to be aware of the different preferences and be sensitive to the associated implications.

Recommendations

The MBTI can be used as a tool to address the patient-centred communication training of pharmacists to support the shift in educational focus. Such communication requires students to be aware not only of their own preferences and communication style, but also of the preferences of patients that are not similar to their own. This knowledge will help pharmacy students to grasp the world from the patient’s perspective, especially in terms of what the patient regards as meaningful. Although the majority of the students preferred Sensing-Feeling, they should be aware of and sensitive to the communication expectations

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of patients with preferences other than their own. Knowing about the behavioural and communication implications of the different MBTI preferences may enable students to move nearer to the ideal of treating their patients with empathy, respect and unconditional regard. Even though there is a very small chance for a pharmacy student to interact with a patient of similar MBTI personality type, the former does not need to know what the personality type of each of their patients is; they only need to be aware of the different preferences and sensitive to the associated implications. Consequently, pharmacy students will recognise the legitimate needs and associated meanings in their patients’ communication.

Conclusion

Knowing personality type will enhance the skills set needed by any pharmacist to address the specific requirements of patient-centredness. A broad understanding of the different preferences and associated communication style implications that the patient might have is key to recognising the different needs of patients. References 1. Stewart M. Towards a global definition of patient centred care. BMJ 2011;322(7284):444-445. [http://dx.doi. org/10.1136/bmj.322.7284.444] 2. Dinsmoor R. What your pharmacist can do for you: A resource often overlooked. Asthma Magazine 2003:27-29. [http://dx.doi.org/10.1067/mas.2003.2] 3. Berenguer B, La Casa C, De La Matta MJ, Martin-Calero MJ. Pharmaceutical care: Past, present and future. Curr Pharm 2004;10(31):3931-3946. 4. Worley MM, Schommer JC, Brown LM, et al. Pharmacists’ and patients’ roles in pharmacist-patient relationship: Are pharmacists and patients reading from the same relationship script? Res Soc Adm Pharm 2007;3:47-69. [http://dx.doi.org/10.1016/j.sapharm.2006.03.003] 5. South African Pharmacy Council. Intern and Tutor Manual for the Pre-registration Experience of Pharmacist Interns. Pretoria: South African Pharmacy Council, 2013:10-33. 6. Boesen KP, Herrier RN, Apgar DA, Jackowski RM. Improvisational exercises to improve pharmacy students’ professional communication skills. Am J Pharm Educ 2009;73:35. [http://dx.doi.org/10.5688/aj730235] 7. Basson MJ, Eksteen MJ. Pharmacists, communication preferences and care. Prague, 2012. http:// www.inter-disciplinar y.net/probing-the-boundaries/wp-content/uploads/2012/04/the-patient2Mari%C3%ABttaBassonMarietEksteen-website-paper.pdf (accessed 26 November 2013). 8. Sims LM, Haines SL. Challenges of a pharmacist-directed peer support program among adolescents with diabetes. J Am Pharm Assoc 2003;51(6):766-769. 9. Myers IB, McCaulley MH. Manual: A Guide to the Development and Use of the Myers Briggs Type Indicator. 2nd ed. Palo Alto: Consulting Psychologists Press, 1985:1-309. [http://dx.doi.org/10.1331/ JAPhA.2011.10041] 10. Catley K, Tipler MJ. National Curriculum Mathematics. Level 6. Christchurch: Caxton Educational, 1997:125. 11. South African Pharmacy Council. Pharmacy Human Resources in South Africa. Pretoria: South African Pharmacy Council, 2011:34. 12. Taylor N, Yianrakis C. South African MBTI® Form M Data Supplement. Johannesburg: Jopie van Rooyen and Partners, 2007:1-25. 13. Dunning D. Introduction to Type and Communication. California: CPP, 2003:1-54. 14. Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med 2011;9(2):100-103. [http:// dx.doi.org/10.1370/afm.1239] 15. Quirk M, Mazor K, Haley HL, et al. How patients perceive a doctor’s caring attitude. Patient Educ Couns 2008;72:359-366. [http://dx.doi.org/10.1016/j.pec.2008.05.022]

Research A lesson in listening: Is the student voice heard in the rush to incorporate technology into health professions education? L Keiller,1 BSc (Physio), MPhil (HSE); G Inglis-Jassiem,2 BSc (Physio), MSc (Physio) 1

C entre for Learning Technologies, Division of Teaching and Learning Enhancement, Stellenbosch University, Cape Town, South Africa

D ivision of Physiotherapy, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Corresponding author: L Keiller (lkeiller@sun.ac.za)

Background. Early indications are that blended learning in health professions education has a positive influence on student satisfaction and learning. This is encouraging, as the call to incorporate technology in teaching and learning in higher education is increasing. The student voice in the planning and implementation of blended learning strategies is, however, not adequately addressed in many of the studies to date. Objective. To utilise videos and blogging in a problem-based learning physiotherapy module to enhance student engagement with content of problembased cases. Methods. Students completed a needs-analysis and engagement questionnaire. Videos made by students were uploaded to the learning management system and subsequent use of these videos was recorded. Two focus group discussions were held to evaluate students’ perceptions of the blended learning strategies. Results. Students perceived the level of engagement during case presentation periods to be satisfactory, but unsatisfactory outside of such periods. Focus group discussions identified the technology used in this study as being inappropriate for this population. Students had specific expectations of the roles of staff and students. There was a perceived lack of skill with regard to the use of the technology chosen. Conclusion. There is a need for the student voice to be heard with regard to both the rationale for implementation and the type of technology used in blended learning strategy innovations. This study recommends that student-generated videos of clinical skills could be implemented successfully with adequate support from staff. Afr J Health Professions Educ 2015;7(1):47-50. DOI:10.7196/AJHPE.371

Blended learning, the ‘thoughtful integration of online and face-to-face-instruction’,[1] is rapidly increasing in the higher education arena. Subsequently, a body of research has begun to develop that investigates the incorporation of technology into teaching and learning practices across disciplines and on various topics.[2] In health professions education, early consensus in the literature was that students were satisfied with e-learning or blended learning – an effective method of instruction.[3] Furthermore, blended learning has been identified as a possible means of bridging the gap between theory and clinical knowledge in health professions education.[4] Included in the body of research related to blended learning in health professions education, the use of videos in presenting patients for problembased learning (PBL) cases has been shown to enhance the overall learning experience and engagement of medical students, and in turn supported a patient-centric perspective in the training of students.[5] This study aimed to add to the body of research on the effectiveness of blended learning and apply the use of technology to a PBL physiotherapy module. The addition of videos and blogging was implemented to enhance the engagement of students in the PBL module by extending the dialogue platform available to the students. The results of the study indicate that planning and implementation of innovation in teaching and learning should be done with careful consideration of student preference and level of competency with new technology. This article is therefore presented to aid health professions educators in their planning during the pre-implementation phase of an innovation in blended learning.

Literature

In the literature, blended learning is often used interchangeably with e-learning. The danger is that technology-enhanced teaching/learning, which might include mostly online teaching approaches, is not adequate in describing what a blended learning approach entails.[6] Blended learning requires educators to adapt the method of instruction and overall planning of their modules. At the core of blended learning, is the underlying premise that teaching and learning practice incorporates both online and face-toface instruction and has been dubbed to be one of the greatest trends in higher education practice within the past 10 years.[7] The literature provides a variety of definitions of PBL. There are six core characteristics that underpin the various definitions of PBL, two of which are that learning is student centred and new information is acquired through selfdirected learning.[8] Research has shown that students exposed to PBL are better equipped in the real world owing to their increased retention of knowledge, enhanced integration and application of basic science concepts into clinical contexts and subsequent enhancement of their intrinsic interest in the subject matter.[9] However, PBL cannot be used in isolation to achieve the level of transfer to the clinical environment to the exclusion of other measures.[10] Using technology together with PBL in a blended learning approach has been found to have a positive impact on students’ learning outcomes.[11] Students have reported a high satisfaction and usage rate of e-learning tools in PBL programmes implemented in medical schools.[12] Ultimately, students and staff alike have found that e-learning enhances both teaching and learning by enabling learners to achieve increased motivation, performance and retention rates of knowledge, skills and attitudes.[3] It would be of value to explore the benefits of this approach within physiotherapy.[13]

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Research A number of authors have expressed concern regarding the apparent focus of blended learning research on technology and institutional benefits to the exclusion of pedagogy and theoretically supported application.[2,6] Where the research has included the student perspective, it reported on their attitudes, knowledge and experience of information, communication and technology tools rather than providing insight into the participatory role in the design and revision of the initiative.[14] There is, however, a trend in higher education research to recognise the student voice more explicitly.[15] Furthermore, the most cited research regarding blended learning largely focuses on the learning outcomes to be reached with implementation of such a strategy,[2] but provides limited insight into the potential that eliciting the student voice in planning these interventions could provide.

Methods

This empirical study was conducted with a group of third-year physiotherapy students enrolled in the Applied Physiotherapy module at the Division of Physiotherapy, Stellenbosch University (SU), South Africa. Ethical approval was granted by the health research ethics committee at the Faculty of Medicine and Health Sciences, SU (N11/07/240). Students (N=40) and staff (N=1) provided their consent to participate in the study.

Context

A hybrid PBL strategy has been the main method of instruction for third-year undergraduate physiotherapy students at SU since 2007. This strategy consists of 36 cases, with a total of 10 hours of contact time available for each case. A case is initiated with a tutorial session on day 1, followed by a practical session on day 2, and a feedback session on day 3. Students would generally begin with the next case on the same day as the feedback session of the preceding one. Module feedback from students and staff has consistently expressed concern with regard to the quality and depth of engagement with case content since inception.

Intervention

Students were invited to attend a training session on how to access and utilise a university-based blogging platform for discussion of case content and for post-study reflections. They were also provided with access to a hand-held video camera, with the aim of recording practical skills done during the practical component of each PBL case.

A self-administered engagement questionnaire was completed by all students prior to and upon completion of the study period[16] (Addendum A). This was preceded by a needs analysis survey that aimed to identify perceptions of the staff and students of the need for enhanced engagement in the module. Videos made by students were loaded on the learning management system and usage statistics monitored. Digitally recorded semi-structured focus group interviews were held with two groups of students immediately after the intervention period. These were transcribed and thematically analysed.

Results

The needs analysis survey was completed by 18 students (45%). The survey identified studentsâ&#x20AC;&#x2122; perceptions of engagement at two different time points, i.e. during the completion of the PBL case and outside of that time period. With regard to engagement over the 3 days in which a case is presented, students perceived themselves to be engaged in the discussion and practical sessions of the cases (Fig. 1). Students have the perception that case materials are unsatisfactory and that they are not provided with enough time to fully engage with

content for each case. They perceived themselves as being less engaged with case content and to have limited ability to recall the practical skills covered in the cases (Fig. 2). The self-administered, validated, engagement questionnaire showed that students perceived that they were actively engaged in PBL cases both prior to and on completion of the study period. With regard to the intervention, one student utilised the video camera to make two videos in a single case practical session. These two videos were accessed 23 times on the learning management system. Students did not access the blogging platform throughout the study period. Five themes emerged from the thematic analysis of the focus group discussions. These are graphically represented in Fig. 3, with supporting quotes for clarification. Students perceived the intervention to be flawed in that they had to spend extra time collecting the video camera, which they considered to be unwieldy, and setting it up during the practical session. This was perceived to be unnecessary use of their time. They were unfamiliar with the practice of blogging and gave this as a reason for not accessing the blog even after the training session they attended for this purpose. Furthermore,

16 14 12 10

I feel that students are actively engaged in discussions during tutorial sessions

I feel that students are actively engaged in practising their techniques in the practical sessions

6 4 2 0 Strongly disagree

Disagree

Neutral

Agree

Strongly agree

I feel that students are actively engaged in discussions during feedback sessions

Fig. 1. Student perceptions of engagement during case sessions. I am satisfied with the current learning material generated from applied physiotherapy cases

9 8 7

I feel that the students are engaging in discussions related to cases after the case has been concluded

6 5 4 3

I feel that students are able to recall practical techniques related to a specific case when needed in the clinical setting

2 1 0 Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Fig. 2. Student perceptions of engagement after case completion.

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I feel that students are given enough time to fully understand and research each case scenario

Research

Student responsibility

• ‘[videos/blogging] Will mean doing double the work.’ • ‘Our class is not ready blogging yet unless it’s for a mark or money.’ Lecturer responsibility

• ‘Lecturers putting important information on blog will encourage students to go to it.’ • ‘Lecturers should bring the video camera into the session.’ Technology issues

• ‘Would be good to have tripod and plinth set up before start of session.’ • ‘I don’t have internet in my room ... [to access blog/video].’ Engagement

• ‘Unless the facilitator is encouraging engagement, students keep quiet.’ • ‘Depends on the group that you are in [on whether or not they are engaged in the case discussion].’ Time

• ‘Not enough time between cases to reflect and fill in the gaps and sharing information between groups.’ • ‘No time for reviewing videos AND going through case work.’ Fig. 3. Themes identified from focus group discussions on the inclusion of blended learning strategies in a problem-based learning module in an undergraduate physiotherapy curriculum.

they indicated that the intervention was not a priority for them as it was not a compulsory assessment-related activity. Finally, students considered it the responsibility of the lecturers to facilitate the increased engagement with cases, also staff-generated videos.

Discussion

Students in the hybrid PBL module responded to the needs analysis survey with their perceptions of a lack of engagement with case material and, worryingly, their inability to recall clinical techniques in relation to specific pathological conditions. This was interpreted by the researchers as a positive indication that the implementation of videos and blogging may be useful to address these issues in addition to the evidence in the literature for a more blended learning approach. However, the lack of participation in the study prompted us to investigate the underlying reasons for the students’ response to the intervention and their expectations with regard to the methods used to increase engagement in PBL sessions. Students’ perceptions, as highlighted by the focus group discussions, were useful in identifying the limitations of the strategies employed in this study. If we as a research team had adequately engaged with students in planning with regard to the technology used and method of generating videos, the possibility of a higher participation level could have been realised. Students perceived the videos of clinical skills as important for their learning,

but ultimately expected lecturers to take responsibility for generating and providing access to the videos. The perception of this cohort is similar to what has been previously reported, where students rate the facilitator/academic staff member as being integral to their ability to become self-directed learners in PBL.[17] Furthermore, the usefulness of clinical simulations in a digitally recorded format, when developed and provided by academic staff, has been shown to be effective in preparation for clinical placements in allied health professions education.[18] One of the most important lessons learnt while conducting this study, was the need to approach innovations in teaching and learning practices as an opportunity to support students to change their modus operandi for learning. Applying principles of change management has been shown to be necessary in an international setting.[19] The eight strategies recommended consist of three phases, the first being to introduce the concept and establish its relevance, then to make it happen, and finally to engage in activities to ensure sustainability.[19] A recommendation from this study is therefore to ensure student participation in the selection of technological devices, method of sharing and availability of recorded techniques. To meet this recommendation, the academic staff would need to investigate the use of mobile devices if students are to participate in the recording of techniques. Should academic staff recognise the need, in consultation with students on the usefulness of these student-generated videos, the assessment opportunity thereof will

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Research need to be investigated. We envisage adding assessed student-generated videos to a database or a repository as a viable option for expanding learning opportunities for undergraduate physiotherapy students. The rationale is that if students are required to demonstrate a clinical skill for assessment purposes, the quality of the videos would be of a sufficient nature for use as a resource. Cell phone technology allows students to use their own devices to record these videos and would therefore eliminate the difficulty students had with the video camera provided for them in this study. The practice of generating their own videos for a database could furthermore have a positive impact on their clinical skills.[20] Alternatively, if physiotherapy curricula should implement the use of video recording for student learning, the following should be considered: infrastructural technology changes to practical venues, provision of technical support, and staff-generated videos of core techniques. The videos would then be a learning resource for students as opposed to an additional task.

Conclusion

This study highlights the necessity for a deeper understanding of the study population in addition to the literature before following the call to include technology in teaching and learning. Evidence from the literature and results of this study support a collaborative effort in the planning of blended learning innovations. Even though the participation level and self-directed learning were not clearly evident, we maintain that technology can be used to enhance engagement for students. In hindsight, success is dependent on sufficient planning and implementation of various strategies to ensure optimal participation and satisfaction of both academic staff and students.

References 1. Garrison DR, Kanuka H. Blended learning: Uncovering its transformative potential in higher education. The Internet and Higher Education 2004;7(2):95-105. [http://dx.doi.org/10.1016/j.iheduc.2004.02.001] 2. Halverson LR, Graham CR, Spring KJ, Drysdale JS. An analysis of high impact scholarship and publication trends in blended learning. Distance Education 2012;33(3):381-413. [http://dx.doi.org/10.1080/01587919.2012.723166] 3. Ruiz JG, Mintzer M, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006;81(3):207-212. [http://dx.doi.org/10.1097/00001888-200603000-00002] 4. Rowe M, Frantz J, Bozalek V. The role of blended learning in the clinical education of healthcare students: A systematic review. Med Teach 2012;34(4):e216-221. [http://dx.doi.org/10.3109/0142159X.2012.642831] 5. Bizzocchi J, Schell R. Rich-narrative case study for online PBL in medical education. Acad Med 2009;84(10):14121418. [http://dx.doi.org/10.1097/ACM.0b013e3181b6ead0] 6. Graham CR, Woodfield W, Harrison JB. A framework for institutional adoption and implementation of blended learning in higher education. The Internet and Higher Education 2012a;18:4-14. [http://dx.doi.org/10.1016/j.iheduc.2012.09.003] 7. Graham C. Blended learning systems: Definition, current trends, and future directions. In: Bonk CJ, Graham CR, eds. The Handbook of Blended Learning: Global Perspectives, Local Designs. San Francisco, CA: Pfeiffer (an imprint of Wiley), 2006:3-21. 8. Hmelo-Silver CE, Barrows H. Goals and strategies of a problem-based learning facilitator. Interdisciplinary Journal of Problem-based Learning 2006;1(1):21-39. [http://dx.doi.org/10.7771/1541-5015.1004] 9. Groves M. Problem-based learning and learning approach: Is there a relationship? Advances in Health Sciences Education 2005;10:15-326. [http://dx.doi.org/10.1007/s10459-005-8556-3] 10. Wittert GA, Nelson AJ. Medical education: Revolution, devolution and evolution in curriculum philosophy and design. Med J Aust 2009;191(1):35-37. 11. Taradi SK, Taradi M, Radic K, Pokrajac N. Blending problem-based learning with Web technology positively impacts student learning outcomes in acid-base physiology. Adv Physiol Educ 2005;29(1):35-39. [http://dx.doi.org/10.1152/advan.00026.2004] 12. Gurpinar E, Zayim N, Ozenci CC, Alimoglu M. First report about an e-learning application supporting PBL: Students’ usages, satisfactions, and achievements. Turkish Online Journal of Educational Technology 2009;8(2):55-62. 13. Willet G. Development of a prototype computer-based instruction module: Foundational neuroscience for physical therapy students. The Internet Journal of Allied Health Sciences and Practice 2004;2(2):1-9. 14. Wilkinson A, While AE, Roberts J. Measurement of information and communication technology experience and attitudes to e-learning of students in the healthcare professions: Integrative review. Journal of Advanced Nursing 2009;65(4):755-772. [http://dx.doi.org/10.1111/j.1365-2648.2008.04924.x] 15. Maunder RE, Cunliffe M, Galvin J, Mjali S, Rogers J. Listening to student voices: Student researchers exploring undergraduate experiences of university transition. Higher Education 2012;66(2):139-152. [http://dx.doi.org/10.1007/s10734-012-9595-3] 16. O’Malley KJ, Moran BJ, Haidet P, et al. Validation of an observation instrument for measuring student engagement in health pressions settings. Eval Health Prof 2003;26(1):86-103. [http://dx.doi.org/10.1177/0163278702250093] 17. Lee Y, Mann K, Frank B. What drives students’ self-directed learning in a hybrid PBL curriculum. Adv Health Sci Educ Theory Pract 2010;15:425-437. [http://dx.doi.org/10.1007/s10459-009-9210-2] 18. Williams B, Brown T, Scholes R, French J, Archer F. Can interdisciplinary clinical DVD simulations transform clinical fieldwork education for paramedic, occupational therapy, physiotherapy, and nursing students? Journal of Allied Health 2010;39(1):3-10. 19. Quinn D, Amer Y, Lonie A, Blackmore K, Thompson L, Pettigrove M. Leading change: Applying change management approaches to engage students in blended learning. Australian Journal of Educational Technology 2012;28(1):16-29. 20. Maloney S, Storr M, Morgan P, Ilic D. The effect of student self-video of performance on clinical skill competency: A randomised controlled trial. Adv Health Sci Educ Theory Pract 2012;18(1):81-89. [http://dx.doi.org/10.1007/ s10459-012-9356-1]

Addendum A Items and scoring guide for the student self-report of engagement measure* 1. I contributed meaningfully to class discussions today. 2. I was not paying attention most of the time in class. 3. I contributed my fair share to class discussions. 4. I participated in class discussions today. 5. I talked in class with other students about class material. 6. I was mostly a passive learner in class today. 7. I paid attention most of the time in class. 8. I was mostly an active learner in class today. 9. Most students were actively involved in class today. Note: Response categories for all items ranged from 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree), to 5 (strongly agree). Subscale totals were calculated by reverse scoring items 2 and 6 and averaging the nine items. *O’Malley KJ, Moran BJ, Haidet P, Seidel CL, et al. Validation of an observation instrument for measuring student engagement in health professions settings. Evaluation and the Health Professions 2003;26(1):86-103. [http://dx.doi.org/10.1177/0163278702250093]

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Research Curriculum challenges faced by rural-origin health science students at South African medical schools P Diab,1 MB ChB, MFamMed; P S Flack,2 BA Sp & HTh, MA, DEd; L H Mabuza,3 MB ChB, BTh, MFamMed, FCFP (SA); H Moolman,4 DCom, MCom, BCom (Hons), BCom, Dip Datametrics 1

Discipline of Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

D iscipline of Speech Language Pathology, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Department of Family Medicine and Primary Health Care, School of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa (formerly University of Limpopo (Medunsa Campus), Ga-Rankuwa, South Africa)

Department of Statistics, Faculty of Science,Walter Sisulu University, Mthatha, South Africa

Corresponding author: P Diab (diabp@ukzn.ac.za)

Background. The current shortage of healthcare workers in rural communities demands attention. The sourcing of rural-origin students (ROSs) has been suggested, but retention of these students in their chosen degrees is crucial. Addressing the tertiary education challenges that ROSs face is critical to ensuring their success. Objective. To focus on the various challenges influencing throughput of ROSs. Method. This article is one of a series of investigations into various aspects of university life and career choices of health science students. Data were collected at three South African universities by the Collaboration for Health Equity through Education and Research (CHEER) collaborators. Ethical permission was sought from each institution. Health science students at the relevant institutions consented to completing a self-administered questionnaire. The data were analysed on SPSS and Ď&#x2021;2 tests were used to describe the statistical significance of the results. Results. Academic course content was the greatest challenge as perceived by students. Differences between rural and urban students were significant in all aspects of university life studied. Technological challenges were five times more common for ROSs. Differences between first- and final-year students were not as marked, although the personal challenges and academic course content became easier as students progressed through their degree. Conclusion. Although ROSs face similar challenges as students of urban origin, in some instances these are enhanced and magnified. These students are more likely to find various aspects of university life challenging. To improve the success and retention of ROSs, adequate support structures are essential. Afr J Health Professions Educ 2015;7(1):51-54. DOI:10.7196/AJHPE.390

There is a critical shortage of healthcare professionals in rural communities in South Africa (SA).[1] The South African National Department of Health (nDOH) is currently considering increasing the intake of medical and health science students in line with national need. There is evidence in both the international and SA literature, to suggest that students from rural origin are more likely to return to rural practice.[2,3] The definition of a rural-origin student (ROS) has come under some debate, but for the purpose of this study it refers to a student who lived in a rural home and attended a rural high school. If we are to encourage ROSs to pursue careers in rural practice, it follows that we need to recruit such students to study the health sciences. This has been a major focus for many SA universities in response to nDOH directives and is not covered in this article. We aim to address the necessity to retain these students once recruited into their chosen health degrees, and ensure their success in obtaining their degrees. To alleviate the stresses associated with health science degrees, we need to identify the challenges that students face and whether ROSs experience these challenges differently from urbanorigin students. We also need to identify such trends throughout the course of study and monitor whether these are mitigated or enhanced. The literature reports a number of difficulties experienced by students as they move from secondary to tertiary education.[4,5] One of the main

difficulties in this transition is the academic content of their chosen field and, for health science students in particular, the added challenge of studying for a professional degree. The language of teaching and learning for students not studying in their mother tongue has been seen to pose problems universally.[6] In SA, secondary schooling is often in the vernacular, but tertiary education is limited to English and Afrikaans. Tertiary study also relies heavily on the use of technology as a vital component to studying. Students are expected to be fully computer literate to fulfil course requirements, especially with the trend towards e-learning. Students not previously exposed to this level of technology have the additional burden of familiarising themselves with the technology, as well as dealing with other challenges of university life. These issues are further confounded by environmental and personal challenges, such as adapting to university life, changing living environments and leaving home.[7,8] Financial concerns also have an overriding impact on student life,[9] even when students receive bursaries and scholarships, as the administration of these monies can be time consuming. The transition to adulthood and financial independence is typically fraught with high levels of anxiety. This article highlights the institutional challenges faced by ROSs, informed by the qualitative phase of this study,[10] which found that

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Research they face a common set of challenges regardless of their institution and/or field of study. These are academic course content, personal (e.g. home background), environmental (e.g. acclimatising to university life) and financial challenges, language of teaching and learning, and technology. The purpose is not to compare universities or even disciplines, but to highlight the broader, common challenges ROSs grapple with. We focus on challenges that do not seem to dissipate as students settle into university life – issues that remain challenging across their entire study period.

for independence were performed to test for significance according to origin (urban, rural) and year of study (first, final). This article represents one of various aspects of the data collected and focuses on the challenges in the curriculum faced by students of rural origin. In other articles students’ motivation to study for a health science degree, support mechanisms in place (pending) and final career choices are discussed.[11] The aim of this study was to determine general trends in challenges faced by students throughout their degree, with a particular focus on ROSs.

Methods

A total of 1 676 questionnaires were returned. Of these, 126 were excluded owing to the students not studying for a health science degree. A total of 1 550 questionnaires were included in the final analysis. The response rate was 52%, spread across all three universities, where 42% were from Z, 33% from X and 25% from Y.

Results

Table 1. Rural-urban classification of participants

Rural school, n (%)

Urban school, n (%)

Total, N (%)

Rural home, n (%)

464 (30.63)

125 (8.25)

589 (38.88)

Urban home, n (%)

64 (4.22)

862 (56.90)

926 (61.12)

Total, N (%)

528 (34.85)

987 (65.15)

1 515

Total Rural 52.7

29.9 22.8

40 30

18.5

30.0

44.5

67.1

Urban

57.1 52.1

61.2 59.2 65.1

64.5 59.1

74.9

81.6 82.7 79.4

20 10

lo hn o Te c

ar g

in ch ft ea eo

La ng u

En vir om

en ta

an d

lle

en all ch na l so

ng es

s ge

ce s an Fin Pe r

co u

rse

co nt en t

Ac a

This article reports on phase two of a study conducted between August and October 2011, which aimed at gaining information on various aspects of university life and future career aspirations of health science students (defined as those registered as student health science professionals) at three South African universities, i.e. University X, University Y and University Z. Although these universities selected themselves to take part in the study, they represent a diversity in terms of universities who traditionally select urban and rural students. Ethical approval for the study was granted by the ethical committees of all three participating universities (X-HSS/0966/09, Z-MREC/M/63/ 2010:IR, and Y-HREC 353/2011). The initial, qualitative phase of the study, reported on in Rural and Remote Health,[10] informed the structure of the questionnaire developed for the latter phase of the study. Data collection at each site was led by the Collaboration for Health Equity through Education and Research (CHEER)[1] collaborators at individual universities. An anonymous, self-administered questionnaire was distributed to all first- and final-year students across all disciplines offered at each participating health science faculty or medical school. The questionnaire included various aspects of students’ intentions to study for a health science degree, the support they required and their future career intentions. With regard to the challenges they faced at university, students were asked to rate each factor as ‘challenging’, ‘highly challenging’ or ‘not challenging’. Participation was voluntary and consent was obtained from each participant individually. Data from the second phase of the study were entered into Epidata at each site, respectively, collated, verified by X, and exported for analysis to SPSS (version 21). Chi-square tests

First- and final-year students were asked to rate the extent to which various aspects of university studies were ‘challenging’, ‘highly challenging’ or ‘not challenging’. Students allocated themselves to ‘rural’ or ‘urban’ categories. This was done because of the broad range of definitions of rural and the lack of consensus in these definitions, which then enabled students to identify with their own understanding of the context. Students were then streamed into groups according to the location of their home and high school (Table 1). Students from a rural home and school are considered rural, while those from an urban school and home are considered urban. For the purpose of this article, only these two categories of students are compared and contrasted, i.e. 464 students who were identified as rural-rural (RR) and 862 identified as urban-urban (UU). It was felt that students who lived in a rural area and attended school in an urban area or vice versa could not be considered as rural or urban,

Fig. 1. Graph showing percentages of students who identified various curriculum issues as ‘challenging’ or ‘highly challenging’.

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Research based on their exposure to or immersion in both contexts. They were therefore excluded for the analysis. The chart in Fig. 1 indicates that academic course content was reported to be the most challenging and technology the least challenging. Although the chart includes both urban and rural students, the majority of students who found these aspects challenging or highly challenging were ROSs. The purpose of the analysis was to investigate differences between students according to base (rural/urban) and year (first/final). The tests discussed were based on the Pearson χ2 test. These tests were used to compare challenges between rural and urban students, depending on their year of study. A small χ2 value indicates that the challenge and factor of interest are not related. A sufficiently large χ2 value indicates that the challenge and factor of interest are significantly related. The smaller the p-value, the more significantly the challenge is related to the factor of interest. As can be seen from Table 2, all results are statistically significant, other than the difference found in the challenge posed by the academic course content for final-

year students. The level to which the results are statistically significant is indicated in the key below the table. In addition, ROSs were almost five times more likely than their urban counterparts to find technology a challenge (5.38:1 odds ratio). When comparing the differences between first- and final- year students, depending on their origin, both the academic course content and personal challenges were less challenging for both rural and urban students by the time they reached their final year, as can be seen in Table 3. There is no statistically significant difference in the challenges posed by the language of teaching and learning, technology and finances from first to final year. However, for rural students, technology is a challenge throughout their studies, as indicated by the χ2 p-value of 0.114. While urban students in their final year found the environment less challenging, rural students did not. Although this is a cross-sectional study and not a longitudinal cohort from first to final year, first- and final-year students found the aspects of university life under discussion to be challenging.

Table 2. Results of χ2 tests comparing rural and urban students, depending on their year of study First year

Final year

Challenge

p-value

Environmental changes

30.685

0.000†

20.039

0.000†

Language of teaching and learning

33.652

0.000†

24.808

0.000†

Technology

104.553

†

0.000

54.965

0.000†

Finances

36.038

0.000†

19.024

0.000†

Academic course content

5.574

0.062*

2.992

0.224

Personal changes

13.269

0.001†

5.086

0.079*

Significant at the 10% level of significance. † Significant at the 0.1% level of significance. *

Table 3. Results of χ2 tests comparing first- and final-year students, depending on their origin Rural

Urban

Challenge

χ2

p-value

χ2

p-value

Environmental changes

4.261

0.119

6.218

0.045†

Language of teaching and learning

0.817

0.665

2.504

0.286

Technology

4.337

0.114

3.233

0.199

Finances

0.610

0.737

0.153

0.926

Academic course content

5.888

0.053*

8.204

0.017†

Personal changes

6.492

0.039

7.064

0.029†

*Significant at the 10% level of significance. † Significant at the 5% level of significance.

†

Discussion

The importance of improving retention of health science and medical students of rural origin is well documented.[2] The literature suggests that students most at risk of drop-out, or non-persistence, are from disadvantaged backgrounds.[11] Globally, ROSs are often from disadvantaged backgrounds. This is also true in SA, where ‘rurality’ typically implies disadvantaged, both socioeconomically and educationally. The results of this study confirm that it is indeed the ROS who finds the environment, language of teaching and learning, technology, finances, academic course content and personal challenges more challenging than urban-origin students. ROSs continue to find most of these aspects challenging throughout their studies. Primary and secondary schooling in rural areas does not adequately prepare them for tertiary education, resulting in these students being at high risk of academic failure.[12,13] The abovementioned results show that urban and rural students found the academic course content most challenging. There was no significant difference between how rural and urban students perceived the challenge. However, final-year rural and urban students reported that they found academic course content less challenging than in the first year. This may be indicative of the adjustment of both groups to academic discourse and university life in general, development of professional identity over the course of their studies or even success of the various academic development and student support initiatives.[14] Traditionally, such initiatives focus on the academic needs of students, without consideration of the link between poor academic performance and other institutional challenges. It would be imprudent to ignore the impact of these challenges on academic performance.[15] Personal challenges were seen to pose more of a problem for rural than urban students, regardless of the year of study. However, for both groups the challenge of personal life was greater in the first year of study. In the case of final-year students, there was no significant difference between rural- and urban-origin students. This could imply that by their final year all students had found ways of dealing with various personal challenges. Nevertheless, personal challenges were ranked as one of the top three challenges in general while studying for a tertiary degree, with 61% of all students perceiving these to be challenging or highly challenging. The impact on other issues, such as academic studies and

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Research financial concerns, should not be overlooked. The impact of personal challenges should be borne in mind when addressing student support initiatives. However, there was no difference in the way first- and final-year ROSs perceived environmental, financial, language of teaching and learning and technology challenges. The most used technology for student teaching and learning is information communication technology, which is a challenge in most developing countries.[16,17] A study among undergraduate medical students in Sri Lanka (a developing country) found that their overall computer literacy was <50%.[18] The study recommended the introduction of computer training in the initial stages of the undergraduate programme. In SA, ROSs have limited exposure to information technology in their schools, which has a negative effect on their preparedness for tertiary education.[19] This is reflected in our study, where rural students were five times more likely to perceive technology as a challenge in their teaching and learning than their urban counterparts. African languages – not English – are mostly spoken in the majority of rural areas in SA. These languages are used at home and for teaching and learning in primary school, and in some cases secondary school. Currently, none of the medical schools or health science faculties in SA offers the core curriculum in an African language. The language for teaching and learning in these institutions is either English or Afrikaans.[19] In the three participating universities, the language of teaching and learning is English. Studies have shown that there is a direct relationship between students’ academic performance and their proficiency in the medium of instruction.[20-22] In our study, rural students found the language of teaching and learning – English – more challenging than the urban students. For health science students, all these challenges may impact on their progress and throughput and may even result in drop-out. It is therefore crucial to address these issues if we are to ensure success for ROSs in health sciences. Therefore, universities should consider specific support tailored to the needs of ROSs in conjunction with regular support offered to all students in terms of the institutional challenges.[15]

Limitations

Universities selected themselves to participate in this study. Although the results give an indication of how ROSs perceive challenges, the findings cannot be generalised from this exploratory study. Furthermore, owing to the cross-sectional nature of the study, we cannot accurately determine trends but only highlight areas that warrant further study. Also, students who dropped out of their studies between the first and final years were not accounted for and can lead to bias when comparing these groups of students.

Recommendations

It is recommended that each university assesses how ROSs perceive the challenges. Addressing these issues, may enable student support structures

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to meet specific needs of ROSs, thus facilitating their overall university experience and success in their course.

Conclusion

The study suggests that the aspects of university life most challenging to first-year health science students are academic and personal challenges. Overall, the ROS found environment, language of teaching and learning, technology, finances and personal difficulties more challenging than their urban counterparts, regardless of whether they were in their first or final year. The only aspect which both urban and rural students found equally challenging was the academic content. A student who feels alienated, alone and unsupported is at high risk for non-persistence or drop-out.[9] Therefore, to improve retention, it is essential to ensure that students feel supported, included and socially integrated at university. 1. References Tumbo JM, Couper ID, Hugo JF. Rural-origin health science students at South African universities. S Afr Med J 2009;99(1):54-56. 2. De Vries E, Reid S. Do South African medical students of rural origin return to rural practice? S Afr Med J 2008;93(10):789. 3. Laven GA, Beilby JJ, Wilkinson D, McElroy HJ. Factors associated with rural practice among Australian-trained general practitioners. Med J Aust 2003;179(2):75-80. 4. Tinto V. Stages of student departure: Reflections on the longitudinal character of student leaving. Journal of Higher Education 1988;59(4):438-455. 5. Clark MR. Negotiating the freshman year: Challenges and strategies among first-year college students. Journal of College Student Development 2005;46(3):296-316. 6. Evans S, Morrison B. Meeting the challenges of English-medium higher education: The first-year experience in Hong Kong. English for Specific Purposes 2011;30(3):198-208. 7. Dodd C, Kirby D, Seifert T, Sharpe D. The impact of high school distance e-learning experience on rural students’ university achievement and persistence. Online Journal of Distance Learning Administration 2009;12(1). 8. Pillay AL, Ngcobo HS. Sources of stress and support among rural-based first-year university students: An exploratory study. South African Journal of Psychology 2010;40(3):234-240. 9. Quarterman J. An assessment of barriers and strategies for recruitment and retention of a diverse graduate student population. College Student Journal 2008;42(4):947-967. 10. Diab P, Flack PS, Mabuza LH, Reid SJY. Qualitative exploration of the career aspirations of rural-origin health science students in South Africa. Rural Remote Health 2012;12:2251. 11. Tinto V. Dropout from higher education: A theoretical synthesis of recent research. Review of Educational Research 1975;45(1):89-125. 12. McMillan WJ, Barrie RB. Recruiting and retaining rural students: Evidence from a faculty of dentistry in South Africa. Rural Remote Health 2012;12:1855. 13. Ross AJ. Success of a scholarship scheme for rural students. S Afr Med J 2007;97(11):1087-1090. 14. Essack S, Juwah C. Peer facilitated mentoring in higher education: Enhancing the quality of learning for first-year students. International Online Journal of Learning and Teaching in Higher Education 2007;1(1):48-67. 15. Kift SM. The next, great first year challenge: Sustaining, coordinating and embedding coherent institution – wide approaches to enact the FYE as ‘everybody’s business’. Proceedings of the 11th International Pacific Rim First Year in Higher Education Conference, An Apple for the Learner: Celebrating the First Year Experience, Hobart, 2008. 16. De Boer S, Walbeek M. Information technology in developing countries: A study to guide policy formulation. International Journal of Information Management 1999;19(3):207-218. 17. Woreta SA, Kebede Y, Zegeye DT. Knowledge and utilization of information communication technology (ICT) among health science students at the University of Gondar, North Western Ethiopia. BMC Med Inform Decis Mak 2013;13(1):1-7. 18. Ranasinghe P, Wickramasinghe SA, Pieris WR, Karunathilake I, Constantine GR. Computer literacy among first year medical students in a developing country: A cross sectional study. BMC Res Notes 2012;5:504. [http://dx.doi. org/10.1186/1756-0500-5-504] 19. Jaffer S, Ng’ambi D, Czerniewicz L. The role of ICTs in higher education in South Africa: One strategy for addressing teaching and learning challenges. International Journal of Education and Development using ICT 2007;3(4). http://ijedict.dec.uwi.edu/viewarticle.php?id=421 (accessed 16 January 2015). 20. Puddey IB, Mercer A. Socio-economic predictors of performance in the Undergraduate Medicine and Health Sciences Admission Test (UMAT). BMC Med Educ 2013;13(1):155. 21. Fernandez A, Wang F, Braveman M, Finkas LK, Hauer KE. Impact of student ethnicity and primary childhood language on communication skill assessment in a clinical performance examination. J Gen Intern Med 2007;22(8):1155-1160. 22. Higgins-Opitz SB, Tufts M. Active physiology learning in a diverse class: An analysis of medical student responses in terms of sex, home language, and self-reported test performance. Adv Physiol Educ 2012;36(2):116-124.

Research Learning approaches used by students in an undergraduate emergency medical care programme C Mosca, BTech Emergency Medical Care; A Makkink, BTech Emergency Medical Care, PDTE; C Stein, BTech Emergency Medical Care, BTech Education (Post-School), PhD (Emergency Medicine) Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, South Africa Corresponding author: C Stein (cstein@uj.ac.za)

Background. Students may primarily use either a deep learning approach (DLA) or surface learning approach (SLA) in response to their perceptions of the intrinsic and extrinsic factors within a given learning environment. By determining the learning approaches of students, one can provide important information on how they learn within an educational programme – information that can be used for various applications with regard to future structure and presentation of programme content. Objectives. To determine which learning approaches (DLA or SLA) were being used by students in the Bachelor of Emergency Medical Care programme at the University of Johannesburg, South Africa, in each academic year of study. Further objectives were to determine which intrinsic and extrinsic factors influenced these choices and to assess whether learning approaches differed significantly between academic years of study. Methods. This study was conducted using a quantitative design and a validated 20-question survey instrument. Data analysis was primarily descriptive, but also focused on whether there was a significant difference in learning approaches between the four years of study. Results. Seventy students participated in the study, giving an overall response rate of 85%. Results showed that most students predominantly used a DLA, and that there was no significant difference between the four academic years of study with regard to the predominant learning approach. More students appeared to be influenced to use a DLA by extrinsic factors than intrinsic factors. Conclusion. Further research is needed to determine why students choose SLAs or DLAs, and the influence of the educational environment on this process. Afr J Health Professions Educ 2015;7(1):55-57. DOI:10.7196/AJHPE.393

The term ‘learning approaches’ is used to describe what students do when engaging in the learning process, and what primarily motivates them to adopt a particular way of learning. Several studies have been conducted to determine the learning approaches that specific groups of students use, and the factors in the various groups that motivate or develop their adopted learning approaches.[1] When defining learning approaches, there are two main categories, i.e. the deep learning approach (DLA) and surface learning approach (SLA). A consistent finding is that learning is a process and that approaches to learning are shaped by both intrinsic and extrinsic factors.[1]

Process of learning

Learning is a lifelong process that is a combination of three distinct variables: presage, process and product. Biggs[2] conceptualised these variables into an interactive and interrelated system that can be used as a framework from which the process of learning can be understood. The presage variable comprises factors that exist before the learning experience (those aspects that the student brings into the learning environment) and is a combination of intrinsic and extrinsic factors. Intrinsic factors consist of the personal and innate character traits of the student and can mean that a student is naturally hard working or not, dedicated or uncommitted, and represents the student’s attitude in the learning process.[1] Extrinsic factors consist of the learning environment into which the student enters and include the structure of the educational programme, prescribed workload, teaching methods and forms of assessment.[1,3] Research has shown that the learning environment alone can push a student towards a DLA or an SLA.[1,2,4,5]

Learning as a process may be shaped by both intrinsic and extrinsic factors.[1] DLAs are associated with the student engaging with, understanding and making personal meaning of the content being learnt. However, SLAs result in the student relying on memorisation and fact recall in a manner that leaves the information unrelated and isolated from the underlying meaning of the content learnt. DLAs are associated with ‘knowledge transformation’ and SLAs with ‘information reproduction’. The primary distinction is that the SLA is generally relied on when the aim of learning is to momentarily perform well in an assessment. This does not reflect the level of competency achieved by the student in the tested subject matter; it is a reflection of their competency in being able to perform for assessments. The opposite is true for the DLA, where the aim of learning lies in the understanding and interpretation of the learning material, with performance in assessments being a secondary, or even consequent, aim.[2,5,6] The Bachelor of Emergency Medical Care (BEMC) is a 4-year professional degree programme leading to registration with the Health Professions Council of South Africa as an Emergency Care Practitioner, the top tier of non-physician prehospital emergency care personnel. No formal study has yet been undertaken to determine student learning approaches and factors that may influence these in the BEMC programme. This knowledge gap makes it difficult for academic staff to understand how students are adapting to the learning content and environment, and limits understanding of whether students are applying appropriate learning strategies within each specific year of study. Additionally, insight regarding learning approaches may provide judgements to be made regarding the appropriateness of the BEMC programme structure and success of employed teaching methodologies.

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Research Objectives

The objective of this study was to determine what learning approaches (DLA or SLA) were adopted by students in each academic year of study and whether these differed significantly between years in a manner consistent with a progression from SLA to DLA between year 1 and year 4. The primary hypothesis was that first-year students would mostly use SLAs and that there would be a transition to an increasingly DLA from year 1 to year 4. Our motivations for this reasoning were based mostly on our anecdotal observations that first-year BEMC students are mainly poorly equipped to deal with a university-level academic workload and may therefore adopt an SLA to cope with passing assessments. Over time, and with academic progression from first to fourth year, we felt that this may change and a DLA may be adopted. We thought that the factors influencing students in this way would most likely be extrinsic and part of the university learning environment.

Methods

scoring system. The main SAL scores were used to determine whether students used a DLA or an SLA. Answers for each specific approach were grouped and combined to reach an overall total. The group of questions with the highest total was considered indicative of the predominant learning approach of that particular respondent. Scores were grouped by academic year of study (first to fourth). Subscale data for surface and deep motive and strategy were also scored according to the questionnaire scoring system and grouped by academic year of study. Differences in main SAL and subscale scores across academic years of study were compared using the Kruskal-Wallis test, as the data in each group were found to be non-normal. SPSS (version 17.0, SPSS Science, Chicago, USA) was used for inferential data analysis and all statistical tests were considered significant at p<0.05.

Results

Response rate data are shown in Table 1. The decrease in student numbers from first to fourth

Questionnaire

The 20-item Biggs R-SPQ-2F questionnaire was used to assess the learning approach that BEMC students chose to adopt â&#x20AC;&#x201C; DLA or SLA.[2] The questionnaire was specifically designed as a sensitive tool to identify student approaches to learning (SAL) and has been previously validated.[7] It also contains a sub-scaling system that allows data interpretation in a way that can identify the factors influencing the learning approach that students use. The motive subscale is used to identify the intrinsic factors that motivate students to adopt either a DLA or an SLA, and the strategy subscale to identify the extrinsic factors of the learning environment that motivate students in this regard.[2]

Study sample and data collection

All students registered for full-time study in the BEMC programme at the University of Johannesburg, South Africa, were invited to take part in the study. Those willing to participate and who signed the appropriate consent form were eligible to take part. Consenting students completed questionnaires before or immediately after scheduled lectures. Ethical approval to conduct the study was obtained from the Faculty of Health Sciences Academic Ethics Committee at the University of Johannesburg.

Data analysis

Closed response data from completed questionnaires were captured onto a spreadsheet application and scored in accordance with the recommended

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year is due mainly to the fact that the BEMC programme was in the process of being phased in as a replacement for the previous National Diploma in Emergency Medical Care and did therefore not have a full complement of students in the third and fourth years. The distribution of grouped main SAL scores across academic years is shown in Table 2. Groupings reflect the predominant approach to learning and participants were placed in either the DLA or SLA group based on their highest SAL score, as described above. Almost three-quarters of participants across all academic years were classified as having a DLA and the remainder an SLA. A trend in proportional classification across the academic years, from first to fourth, can be seen in Table 2, with a progressive increase in those classified as having a DLA and a corresponding decrease in those with an SLA. Results from analysis of the questionnaire subscales are shown in Table 3.

Table 1. Student responses by academic year Academic year of study

Total responses, n

Registered students, n

Response rate, %

First year

Second year

Third year

Fourth year

Total

Table 2. Distribution of main SAL score groupings across academic years Academic year of study

Deep approach, n (%)

Surface approach, n (%)

First year

20 (67)

10 (33)

Second year

11 (69)

5 (31)

Third year

14 (82)

3 (18)

Fourth year

6 (86)

1 (14)

Total

51 (73)

19 (27)

SAL = student approaches to learning.

Table 3. Distribution of SAL deep and surface subscale score groupings across academic years Academic year of study

Deep motive, n (%)

Deep strategy, n (%)

Surface motive, n (%)

Surface strategy, n (%)

First year

14 (47)

6 (27)

10 (33)

Second year

4 (25)

7 (44)

5 (31)

Third year

4 (24)

10 (59)

3 (18)

Fourth year

1 (14)

5 (71)

1 (14)

Total

23 (45)

28 (55)

19 (100)

SAL = student approaches to learning.

Research Of the 51 participants classified as adopting a DLA, more were classified as adopting a deep strategy than being intrinsically motivated to follow a DLA. Furthermore, the proportion of participants falling into the deep motive category progressively decreased across academic years of study, while there is a corresponding increase in the proportion of participants classified as deep strategy. No participants in the SLA group indicated that they were motivated to do so by intrinsic factors. Results of the Kruskal-Wallis test were used to test the null hypothesis that there was no difference in SAL main or subscale scores of learning approach across the four academic years of study (Table 4). No significant differences were found for any of the SAL scores.

Discussion

The results of this study show a large proportion of students adopting a DLA from their first academic year of study and this proportion increases further over the four years of study. These findings are in line with data from similar studies. This pattern has been seen in studies using either the Biggs SPQ instrument or the Entwistle-Ramsden Lancaster Approaches to Studying Inventory.[8-10] However, the findings of the study by Martenson[11] showed that an SLA among four cohorts of medical students was the predominant approach. About two-thirds of first-year participants were classified as using a DLA; this was unexpected and contrary to our hypothesis of a predominantly SLA in this group. We reasoned that the academic workload and transition from school to university in a cohort that we have observed over time as being relatively poorly prepared for university study would induce an SLA, if this had not already been the dominant approach for many participants at school.

Our results showed a 19% increase in the proportion of participants classified as adopting a DLA from first to fourth year (Table 2). This trend is in keeping with the literature, suggesting that many adult students tend to develop their use of DLA over time – from junior to more senior academic levels of study. In many cases, this appears to be intrinsically driven as students develop skills required to apply DLAs.[1-3,7] Subscale data on whether the primary motivation for the dominant learning approach was intrinsic or extrinsic offer some additional information regarding the participants in our study. Responses summarised in Table 3 suggest that roughly half of the participants in the first year of study were intrinsically motivated to adopt a DLA, i.e. they brought this learning approach with them into the learning environment. However, about one-quarter of participants in the same group were extrinsically motivated to adopt a DLA, suggesting that they did this in response to the academic demands of the learning environment in which they found themselves.[1,4,6] Entwistle and Ramsden[12] have suggested that the learning approach of students is ultimately influenced by the learning environment and that effective learning is the result of a unique combination of the student’s preferred orientation to learning and the learning environment itself. The progression over four academic years of study, with intrinsic motivation for a DLA becoming less prevalent and extrinsic motivation more prevalent (Table 3), suggests that the learning environment, including teaching methodologies and assessment practices, may become more of a driver to adopt a DLA. This is mirrored by the SLA subscale results, showing a decreasing prevalence of extrinsic motivation for participants to follow an SLA from first through to fourth year. No participants were identified as being intrinsically motivated to adopt an SLA.

Table 4. Results of the Kruskal-Wallis test: Difference in main student approaches to learning and subscale scores between academic years χ

Deep

Surface

Deep motive

Deep strategy

Surface motive

Surface strategy

2.626

3.154

0.301

6.696

1.384

4.493

0.453

0.369

0.960

0.082

0.709

0.213

df = degrees of freedom.

Although our study provides valuable information on the adoption of SLAs and DLAs by students in our programme, more work is needed to understand in greater detail what drives these choices and in particular the role of the learning environment in this process. The proportional decrease across the four years of study in students adopting a deep motive (Table 3) in particular, is a trend of some importance for future investigation and monitoring over time. Future research in this area should be designed to follow one or more cohorts of students over the four years, which may clarify whether the trend observed in this study is still present longitudinally and, if so, whether any kind of intervention may be appropriate.

Limitations

The sample used for this study was relatively small, although it comprised a cross-sectional picture of almost the entire BEMC programme in our department at the time. The small number of fourth-year participants makes broader interpretation of the results difficult and there is a possibility that variance in this group may increase in future with increased size of the group. The small sample, and the very small fourth-year group size, increases the possibility of a Type II error in results of the inferential analysis presented in Table 4. References 1. Beattie V, Collins B, Mc Innes B. Deep and surface learning: A simple or simplistic dichotomy? Account Educ 1997;6(1):1-12. 2. Biggs J, Kember D, Leung DYP. The Revised Two Factor Study Process Questionnaire: R-SPQ-2F. Br J Educ Psychol 2001;71:133-149. 3. Alkadhi S. Learning Theory: Adult Education: Andragogy. [Dissertation] Monterey Bay, Calif.: California State University, 2008. 4. Ames C. Classrooms: Goals, structures, and student motivation. J Educ Psychol 1992;84(3):261-271. [http://dx.doi.org/10.1037/00220663.84.3.261] 5. Ramsden P. The context of learning in academic departments. In: Marton F, Hounsell D, Entwistle N. The Experience of Learning: Implications for Teaching and Studying in Higher Education. 3rd ed. Edinburgh: University of Edinburgh, Centre for Teaching, Learning and Assessment, 2005:198-213. 6. Entwistle N. Promoting deep learning through teaching and assessment: Conceptual frameworks and educational contexts. TLRP Conference, Leicester, November 2000. http://www.ed.ac.uk/etl/docs. entwistle.pdf (accessed 8 October 2013). 7. Lizzio A, Wilson K, Simons R. University students’ perceptions of the learning environment and academic outcomes: Implications for theory and practice. Stud High Educ 2002;27(1):27-52. [http://dx.doi. org/10.1080/03075070120099359] 8. Newble DI, Gordon MI. The learning style of medical students. Med Educ 1985;19(1):3-8. 9. Emilia O, Mulholland H. Approaches to learning of students in an Indonesian medical school. Med Educ 1991;25(6):462-470. 10. Mattick K, Knight L. The importance of vocational and social aspects of approaches to learning for medical students. Adv Health Sci Educ Theory Pract 2009;14(5):629-644. 11. Martenson D. Students’ approaches to studying in four medical schools. Med Educ 1986;20:532-534. 12. Entwistle N, Ramsden P. Understanding Student Learning. London: Croom Helm, 1983:209.

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Research Development of an evaluation matrix for a community-based interdisciplinary health-promotion course F Waggie, BSc (Physiotherapy), MSc (Physiotherapy), PhD Interdisciplinary Teaching and Learning Unit, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa Corresponding author: F Waggie (fwaggie@uwc.ac.za)

Background. In order to conduct a thorough and comprehensive evaluation of a curriculum, there must be a framework to guide the process that is needed to evaluate various aspects of the education programme. The Concept-Indicator-Method was chosen and modified as the conceptual framework that steered the evaluation process of a community-based interdisciplinary health-promotion course. Objective. This article draws attention to the development of an appropriate evaluation matrix based on the Concept-Indicator-Method, which served as the organising framework for the evaluation. The focus of the evaluation was on assessing the perceived effectiveness and impact on the stakeholders of the course so as to direct the teaching and learning of health promotion at higher education institutions. Methods. The mixed-methods approach was selected as the most appropriate research design for data collection and analysis. The use of multiple data collection instruments and sources provided a broader perspective and deeper understanding of the core concepts of the evaluation from the perspective of multiple sources. Results. Three core concepts were identified in the evaluation of this community-based undergraduate programme: (i) curriculum; (ii) community-based learning; and (iii) university-school collaboration. Furthermore, associated key indicators for each core concept were developed. Conclusion. The evaluation matrix may be of particular interest to those who are seeking an evaluation tool for evaluating a community-based course. Afr J Health Professions Educ 2015;7(1):58-63. DOI:10.7196/AJHPE.432

A comprehensive approach to curriculum evaluation is deemed an essential aspect of the process of developing healthcare professionals capable of addressing the changing health needs in South Africa (SA) and elsewhere.[1] To conduct a thorough and comprehensive evaluation, there must be a framework that serves as a roadmap, clarifying the steps needed to evaluate the various aspects of an education programme. A conceptual framework is therefore a necessary step in evaluation, and its function is to act as a data organiser and to guide the instrument development and data analysis.[2] Over the past few years, a multiconstituency approach has been developed and used in the evaluation of a range of community-based learning activities.[3] This approach was referred to as the ConceptIndicator-Method.[4] It was initially developed at Portland State University, Oregon, USA, as part of an assessment of their general education programme and designed to assess the impact of service learning on students, lecturers, the institution and the community.[3] The Concept-Indicator-Method provides a framework to guide the evaluation, facilitate the data collection and report in a practical way that is true to the aims and objectives of the evaluation.[5] While evaluators are guided by the experiences of using different methods, no single evaluation template fits all curricula, and the peculiarities of each situation determine the evaluation strategy.[4,6] The Concept-Indicator-Method was seen as an appropriate framework for evaluating an interdisciplinary healthpromotion course offered at the University of the Western Cape, Bellville, SA. The literature presents many definitions of programme evaluation. For instance, it can be defined as periodic assessment of the relevance, performance, efficiency and impact of a project in relation to the stated objectives,[7] and is concerned with the systematic gathering and interpretation of information about a programme. The information is then used to make informed decisions about programme development and management. It is a distinct activity aimed at improving rather

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than proving.[8] In brief, programme evaluation encompasses a multidimensional approach that involves a process of determination of the merit of a programme, identifying relevant standards of merit, worth, or value (criteria); investigation of the performance of the objects (key concepts) of the evaluation as it relates to these standards; and integration or synthesis of the results to achieve an overall evaluation for the purpose of improving the programme.[9,10]

Context

A community-based interdisciplinary health-promotion course offered at a university in SA presented many challenges to the students, lecturers and educators at the 10 schools where the course was given. The purpose of the course was to create a mutually beneficial relationship in which the school became a site of learning for students, and where the school would benefit through the healthpromotion expertise and resources provided by the university. The content of the interdisciplinary health-promotion course includes aspects that contribute to the knowledge base of health promotion, such as the origin and evolution of global health promotion, theory underpinning health-promotion practice, and research, planning and evaluation. It also contributes to the skills competency needed in health-promotion practice, such as professional development, programme planning, implementation and evaluation, communication, interdisciplinary learning, research, facilitation and working with specific target groups. After 2 years it became evident that the purpose of this course was not being optimally met. There was a lack of visible and co-ordinated healthpromotion efforts, and initiatives appeared to be isolated and limited to student projects carried out in one semester of the academic year. This indicated that the interdisciplinary health-promotion course had to be reviewed, particularly in terms of the curricular component, teaching and learning approach, roles and responsibilities of all the stakeholders, and sustainability of health-promotion programmes in the schools.[11]

Research Table 1. Aim and objectives of the evaluation The aim of the evaluation was to assess the perceived effectiveness and impact on the stakeholders of the interdisciplinary health-promotion course to develop an appropriate framework to guide the teaching of health promotion at higher education institutions in South Africa The objectives of the evaluation were: • To describe the process undertaken in the design and implementation of the interdisciplinary health-promotion course • To explore the perceptions and experiences of the key stakeholders, i.e. the university students, lecturers, supervisors and school educators involved in the interdisciplinary health-promotion course in relation to the course curriculum, including the community-based learning approach to teaching and learning • To explore the nature and extent to which collaboration between the university and participating schools were pursued • To explore how the interdisciplinary health-promotion course could be strengthened or improved to better achieve its goals • To develop a framework that is most appropriate for teaching community-based health promotion to an interdisciplinary group of health sciences students in school settings

This article provides a detailed description of the development of an evaluation matrix that represents the organising structure for evaluating the impact of the interdisciplinary health-promotion course on multiple stakeholders. The evaluation was designed to answer the questions relating to the perceptions and experiences of the interdisciplinary health-promotion course and its impact on various stakeholders in the university and primary schools situated in disadvantaged communities.

Table 2. Core concepts and key indicators Core concept

Key indicator

Curriculum

Course design Faculty staff Assessment Teaching and learning interaction

Conceptual framework

The Concept-Indicator-Method approach provided a framework that guided the evaluation in this study; it also enabled the researcher to clearly present the structure for the evaluation, and facilitated data collection and reporting in a practical way that was true to the aim and objectives of the evaluation.[5] The Concept-Indicator-Method approach involves four primary questions: (i) ‘What do we want to know?’ This helps the evaluator to articulate the aim of the assessment; (ii) ‘What will we look for?’ This leads the evaluator to identify core concepts that are derived from the objectives of the evaluation; (iii) ‘What will we measure?’ For each core concept, relevant measurable indicators are specified that will enable the evaluator to measure change or status; (iv) ‘How will we gather the evidence to demonstrate what we want to know?’ At this stage, the evaluator identifies or develops appropriate methods and tools by which to collect the information for each indicator, and identifies sources of data. To understand the complex nature of this community-based, interdisciplinary course and the nature of the university-school collaboration, the ConceptIndicator-Method,[5] as described above, was modified and adopted as the conceptual framework for the evaluation of the interdisciplinary healthpromotion course. The Concept-Indicator-Method approach was modified to consist of five instead of four components,[5] i.e. (i) core concepts; (ii) key indicators; (iii) criteria; (iv) methods; and (v) source of information. The last component was added to the evaluation matrix as it directs the researcher towards where to access the information. The development of an evaluation matrix framed the evaluation plan, guided the development of the evaluation instruments, and structured the data analysis and reporting. The following section describes how the evaluation matrix was developed for a communitybased interdisciplinary health promotion course.

Developing the evaluation matrix

The first step in the development of the evaluation matrix, was to clearly articulate and clarify the aim and objectives of the evaluation (Table 1). This involved answering the first question: ‘What do I want to know?’

Learning materials and resources Course administrator service Course impact Community-based learning

Philosophy and principles Faculty and student interaction Sensitivity to cultural diversity Co-ordination of community-based learning Role/s of stakeholders in communitybased learning Personal and professional development of stakeholders

University-school collaboration

Nature of the collaboration

The second step in the development of an evaluation matrix, was the identification of the core concepts of the evaluation. The following question guided the development of the core concepts: ‘What are the major areas that this evaluation addresses?’ The core concepts are broad topic areas that are derived from the aim and objectives of the evaluation. These concepts formed the foundation of the evaluation in terms of the discussion and elaboration on how this evaluation aims to affect each concept. In an effort to be comprehensive in identifying the core concepts, indicators and criteria for the evaluation of the interdisciplinary healthpromotion course, three policy documents[12-14] and a number of other related articles in the literature were consulted.[8,15-20] Based on the aim and objectives of the evaluation, and the relevant documents and literature consulted, the following three core concepts (Table 2) were identified in the evaluation of this undergraduate programme, i.e. (i) curriculum; (ii) community-based learning; and (iii) university-school collaboration. (University-school collaboration refers to the collaboration between the university and primary schools where the students conducted their fieldwork.)

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Research

Table 3. Core concepts, key indicators, criteria, methods and sources Core concept

Key indicator

Criteria

Method

Source

Curriculum

Course design

The interdisciplinary health-promotion course is designed as an integral part of the facultyâ&#x20AC;&#x2122;s vision and mission The outcomes of the interdisciplinary health-promotion course meet the needs of all the stakeholders involved in the course

Questionnaire Focus group discussion Document analysis

Students Lecturers Supervisors Faculty yearbook Student workbook

The outcomes of the interdisciplinary health-promotion course meet the needs of all the stakeholders involved in the course

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

The interdisciplinary health-promotion course is intellectually credible

Questionnaire Focus group discussion

Students Lecturers Supervisors

The interdisciplinary health-promotion course is coherently designed

Questionnaire Focus group discussion

Students Lecturers Supervisors

The interdisciplinary health-promotion course articulates well with other courses in the disciplineâ&#x20AC;&#x2122;s specific programmes

Questionnaire Focus group discussion

Students Lecturers Supervisors

The lecturing staff are competent to teach the course and are effective in their teaching approach

Questionnaire Focus group iscussion

Students Lecturers

The assessment competence of the lecturing staff is adequate for the nature and level of the course

Questionnaire Focus group discussion

Students Lecturers

There is sufficient faculty staff to ensure that all activities related to the course are realised

Document analysis Minutes of curriculum task team

Student workbook

Assessment is an integral part of the teaching and learning process

Questionnaire Focus group discussion

Students Lecturers Supervisors

Assessment is recognised as a key motivator of learning to inform teaching practice and improve the curriculum

Questionnaire Focus group discussion

Students Lecturers Supervisors

Policies and procedures exist for monitoring student progress

Questionnaire Focus group discussion Document analysis

Students Lecturers Supervisors Student workbook

Policies and procedures exist to ensure validity and reliability of assessment practices and recording of results

Questionnaire Focus group discussion Document analysis

Students Lecturers Supervisors Student workbook

Teaching and learning methods are appropriate to achieve the purpose and outcomes of the course

Questionnaire Focus group discussion

Students Lecturers Supervisors

Interdisciplinary teaching and learning is a key principle in the delivery of the course

Questionnaire Focus group discussion

Students Lecturers Supervisors

Sufficient, relevant and up-to-date library resources are available to students and staff

Questionnaire Focus group discussion

Students Lecturers Supervisors

Learning materials are appropriate to ensuring achievement of the purpose and outcomes of the course

Questionnaire Focus group discussion

Students Lecturers Supervisors

Faculty staff

Assessment

Teaching and learning interaction

Learning materials and resources

Continued ...

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Research

Table 3. (continued) Core concepts, key indicators, criteria, methods and sources Core concept

Communitybased learning

Key indicator

Criteria

Method

Source

Course administration services

The interdisciplinary health-promotion course is co-ordinated by a task team to ensure that course outcomes are met

Document analysis

Curriculum task team minutes

Efficient administrative service for the interdisciplinary health-promotion course exists

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

Suitable, sufficient and accessible venues are available

Questionnaire Focus group discussion

Students Lecturers Supervisors

Course impact

The interdisciplinary health-promotion course succeeded in having an impact on all stakeholders, i.e. students, faculty staff and school community

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

Philosophy and principles

Community-based learning philosophy and principles are understood by the university students and staff

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

The community-based learning experience meets the needs of all the stakeholders

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

Students and university staff are prepared for communitybased learning

Questionnaire Focus group discussion

Students Lecturers Supervisors

Monitoring and supervision are done systematically and regularly

Questionnaire Focus group discussion

Students Lecturers Supervisors

Sensitivity to cultural diversity

The students, lecturers and supervisors are comfortable working in a culturally diverse community

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

Co-ordination of communitybased learning

The co-ordination of community-based learning is efficient

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

Role/s of stakeholders in communitybased learning

The role of the stakeholders in community-based learning is understood

Focus group discussion

Students Lecturers Supervisors Educators

Personal and professional development of stakeholders

The community-based learning contributes to the personal and/or professional development of all stakeholders

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

Nature of the collaboration

There is a common understanding of the concept of partnership between the stakeholders, and a partnership exists between the university and the schools

Questionnaire Focus group discussion

Students Lecturers Educators

The collaboration is beneficial for all stakeholders

Questionnaire Focus group discussion

Students Lecturers Supervisors Educators

The collaboration between the university and the school is sustained

Questionnaire Focus group discussion

Students Lecturers Educators

Faculty and student interaction

Universityschool collaboration

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Research

Table 4. Instruments and sources of data Sources of data Data collection phase

University students

Lecturers

Educators

Supervisors

Quantitative (questionnaires)

All the university students who participated in the interdisciplinary healthpromotion course during 2006 (N=321)

All the lecturing staff who taught the interdisciplinary health-promotion course during 2006 (N=12)

All the educators at the 10 primary schools who had university students placed in their classrooms for the interdisciplinary healthpromotion course during 2006 (N=88)

All the supervisors who supervised the university students in the schools and participated in the interdisciplinary healthpromotion course during 2006 (N=6)

Qualitative (focus group discussions)

Purposive sample group of university students from each professional programme who participated in the interdisciplinary health-promotion course during 2006 (n=72)

All lecturing staff who taught the interdisciplinary health promotion course during 2006 (N=12)

Purposive sample group of educators (key informants) at the 10 primary schools who had university students placed in their classes for the interdisciplinary healthpromotion course during 2006 (n=10)

All the supervisors who supervised the university students in the schools and participated in the interdisciplinary healthpromotion course during 2006 (N=6)

Document analysis

Content analysis was conducted in terms of the criteria that were developed in the evaluation matrix on the following documents: (i) interdisciplinary health-promotion student workbook, 2006; (ii) minutes of the interdisciplinary healthpromotion curriculum task team during 2006; and (iii) Faculty of Community and Health Science Yearbook, 2006

Furthermore, associated key indicators (Table 2) were developed to reflect each core concept evaluated. Indicators are variables that reflect the phenomenon (core concept) that is to be evaluated.[5] Table 2 indicates the core concepts with the associated key indicators. The third step in establishing the evaluation matrix, was to develop the criteria associated with each key indicator (Table 3). A criterion is a standard against which judgement may be made.[6] Criteria also set broad benchmarks for quality assurance in higher education.[13] The criteria were used to examine the specific factors related to each core concept that was evaluated. There is, therefore, a direct linear relationship between each core concept and the related criterion. The questions that guided the development of the criteria were: (i) ‘What can be observed that will provide insights into the core concept?’ (ii) ‘What measures can be explored as evidence of how the core concept is affected?’ and (iii) ‘What evidence exists to show that the core concepts are being addressed?’ The fourth step in the development of the evaluation matrix, was to identify the instruments that would be used to gather the information (Table 3). The following question guided the identification of the instruments: ‘How will I gather the evidence needed to demonstrate what I want to know?’ To understand the complex nature of this community-based, interdisciplinary course and the nature of the university-school collaboration, the explanatory sequential mixed-methods approach was selected as the most appropriate research design for the data collection and analysis. Three methods were identified to collect the information: questionnaires; focus group discussions; and document analysis. The quantitative data helped to develop a picture of the demography of each stakeholder, to ascertain their perceptions and experiences of the course, to understand their perspectives on community-based learning and the collaboration between the university and the school, and to provide recommendations for enhancement of the programme. The qualitative data further explored the emerging themes from the quantitative data.

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Therefore, the qualitative phase built on the quantitative phase, and provided a follow-up in-depth exploration of the quantitative results. Finally, inferences were drawn from both the quantitative and qualitative findings. Table 3 illustrates the complete evaluation matrix that was used to assess the perceived effectiveness and impact on the stakeholders of the community-based interdisciplinary health-promotion course. The fifth and final step in the development of the evaluation matrix, was the identification of the sources from whom or from where the information would be obtained. The following question guided the identification of the sources: ‘From whom and from where will I obtain the necessary information?’ The use of multiple data collection instruments and sources provided a broader perspective and deeper understanding of the core concepts of the study from the perspectives of multiple sources. Table 4 illustrates the data collection instruments and sources of data. While there is a direct relationship between the core concepts and related indicators, there is no such relationship between core concepts, methods and sources. Some of the methods were used for a particular criterion, and some of the sources provided data for a particular method, but not all the sources were involved in each method, and not all methods addressed every criterion.

Conclusion

The use of a conceptual framework becomes vital to guide a comprehensive evaluation of an educational programme. The community-based interdisciplinary health-promotion course was evaluated in terms of its content, teaching and learning approach, and the extent to which it has collaborated with other sectors outside the university. However, it needs to be highlighted that the modified Concept-Indicator-Method developed in this study has not been tested against any other evaluative method; therefore, its current efficacy as an evaluative tool is unclear. I have presented the five steps that guided the development of the evaluation matrix for a community-based health-promotion course. It

Research is important to view the use of this evaluation matrix as a strategy for improving the course; identifying strengths and areas for improvement; identifying deficiencies; providing evidence that will serve as the basis for future planning and enhancements; validating existing knowledge; and providing data to support the continuation of such curriculum activities. Increasingly, multi-stakeholder participation in community-based course evaluations is becoming the norm, while previously much of the literature focused on the impact of community-based education programmes on students as individuals and on their learning.[3] This study is therefore particularly valuable in providing a comprehensive framework when seeking to document the effect of pedagogy across stakeholders. The comprehensive framework is vital because it assists in providing strategies that indicate whether the course is making a difference to those involved in pursuing it. However, in this study the interdisciplinary education aspect of the course is not evaluated in any depth. Lastly, the evaluation matrix may be of particular interest to those who are seeking an organising structure for evaluating a community-based interdisciplinary course. References 1. Musal B, Taskiran C, Gursel Y, Ozan S, Timbil S, Velipasaoglu S. An example of program evaluation project in undergraduate medical education. Educ Health (Abingdon) 2008;21(1):113. 2. Durning SJ, Hemmer P, Pangaro LN. The structure of program evaluation: An approach for evaluating a course, clerkship, or components of a residency or fellowship training program. Teach Learn Med 2007;19(3):308-318. 3. Gelmon S. How do we know that our work makes a difference? Assessment strategies for service-learning and civic engagement. Metropolitan Universities 2000;11(2):28-39.

4. Gelmon S, McBride L, Hill S, Chester L, Guernsey J. Evaluation of the Portland Healthy Communities’ Initiative 1996 - 1998. Portland, Oreg.: Portland State University, 1998. 5. Gelmon S, Foucek A, Waterbury A. Program Evaluation: Principles and Practices. 2nd ed. Portland, Oreg.: Northwest Health Foundation, 2005. 6. Bandaranyake R, Craig P, Wagner R. Multidimensional approach to evaluating a changing curriculum. Annals of Community Oriented Education 1992;5:159-166. 7. Nutbeam D. Evaluating health promotion – progress, problems and solutions. Health Promotion International 1998;13(1):27-44. 8. Mertens DM. Research Methods in Education and Psychology: Integrating Diversity With Quantitative and Qualitative Approaches. Thousand Oaks, Calif.: Sage Publications, 1998. 9. Rotem A. Evaluation to improve educational programmes. Annals of Community Oriented Education 1992;5:135-141. 10. Rossie P, Lipsey M, Freeman H. Evaluation: A Systemic Approach. 7th ed. Thousand Oaks, Calif.: Sage Publications, 2004. 11. Waggie F, Gordon N, Brijlal P. The schools, a viable educational site for interdisciplinary health promotion. Educ Health (Abingdon) 2004;17(3):303-312. 12. University of the Western Cape. Policy for Programme Reviews at UWC. Bellville: University of the Western Cape, 2005. 13. Higher Education Quality Committee. Criteria for Programme Accreditation. Pretoria: Council on Higher Education, 2004. 14. Higher Education Quality Committee. A Good Practice Guide and Self Evaluation Instrument for Managing the Quality of Service-Learning. Pretoria: Council on Higher Education, 2006. 15. Ruhe V, Boudreau JD. The 2011 Program evaluation standards: A framework for quality in medical education programme evaluations. J Eval Clin Pract 2013;19(5):925-932. [http://dx.doi.org/10.1111/j.13652753.2012.01879.x] 16. Velema JP, Finkenflu HJM, Cornielje H. Gains and losses of structured information collection in the evaluation of ‘rehabilitation in the community’ programmes: Ten lessons learnt during actual evaluations. Disabil Rehabil 2008;30(5):396-404. 17. Loots A. Programme evaluation: Maintaining quality in higher education. South African Journal of Higher Education 2008;22 (6):1212-1228. 18. Kristina TN, Majoor G, Van der Vleuten C. Does CBE come close to what it should be? A case study from the developing world. Evaluating a programme in action against objectives on paper. Educ Health 2005;18(2):194208. 19. Long B, Larsen P, Hussey L, Shirley S, Travis A. Organizing, managing, and evaluating service-learning projects. Educational Gerontology 2001;27(1):3-21. 20. Shannon C, Baker H, Jackson J, Roy A, Heady H, Gunel E. Evaluation of a required statewide interdisciplinary rural health education program: Student attitudes, career intents and perceived quality. Rural Remote Health 2005;5(4):405.

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Book review The Primary Health Care Approach and Restructuring of the MB ChB: A Case Study at the Faculty of Health Sciences, University of Cape Town By Nadia Hartman. Lambert Academic Publishing, 2014. ISBN: 978-3-8484-4941-5. info@lap-publishing.com

This is a significant book in many ways, and essential reading for anyone involved in health sciences education. It is important for three reasons: firstly, it is a South African product, and more scholarship grounded in the African context is sorely needed. Secondly, it is originally conceptualised and rigorously constructed, based on the challenging experience of curriculum

restructuring over a number of years, ‘wrested from the vicissitudes of curriculum reform’, as a colleague put it. And, thirdly, but most importantly, it succeeds in doing what many might imagine as impossible, namely to measure the primary healthcare approach (PHCA) in education. PHC is often misunderstood, and either equated with primary care/first-contact care, or lost in a confusing array of jargon that begins with vaguely remembered phrases from the Alma-Ata Declaration of 1978. However, that was more than 35 years ago, and although it still remains relevant in terms of the imperative of Health for All, a significant shift occurred in 2008. The World Health Report of that year by the World Health Organization, ‘Primary Health Care: Now More than Ever’, included a central chapter entitled ‘Putting people first’, indicating a move away from a purely public health orientation towards a more balanced relationship between clinical practice and public health. The ideas of community-orientated primary care have come to the fore once again, more than 50 years after these were first proposed, and the biomedical approach that is applicable to individual patient care is balanced with the need for a wider view of health at a community level. Thus, the author constructs out of the literature and a series of carefully documented key informant interviews, a hierarchy of understanding of the PHCA for educational purposes: from the biopsychosocial approach, through comprehensive care, through the PHC principles to the PHC philosophy. Using her sociological background, she then rates each on a scale from very limited embodiment to full embodiment, indicating the degree of implementation of the PHC philosophy in practice. This framework is used to construct

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a PHCA Index, which is then systematically applied to the University of Cape Town’s MB ChB programme, examining the Faculty of Health Sciences’ strategic plan, the curriculum blueprint, and the programme itself. The author chooses a case study approach of one university to describe the issues to the necessary level of complexity, which works well. Not surprisingly, the results show a lack of curriculum alignment when placed under the spotlight of the PHCA Index, and a tendency to default to the biomedical approach in actual implementation, particularly later in the curriculum, despite the explicit intention to follow the PHC approach. For an explanation of the discrepancy between intention and practice, she turns to Pierre Bourdieu’s theory of habitus, agency and power, which is brilliantly applied to the study. This rigorous analysis not only allows a depth of understanding of educational development that has not been documented before, but gives deep insight into the underlying dynamics of the inherent tensions and assumptions that are frequently made in revising and reconstructing curricula. Most importantly, however, it demonstrates from an educational perspective, in its conceptualisation and execution, what it means to take PHC seriously. It deserves to be read and digested by all health science educators who are prepared to look below the surface of their teaching practices and examine their underlying assumptions. Steve Reid Primary Health Care Directorate Faculty of Health Sciences University of Cape Town South Africa steve.reid@uct.ac.za

Research Correspondence Storymaking: An inter-professional learning experience

To the Editor: In response to the Editorial in the May 2014 edition of AJHPE,[1] I would like to offer an example of medical students who were given an opportunity to engage in inter-professional learning. In July 2014, I supervised a special study module (SSM) for second-year medical students at the University of Cape Town (UCT). Students could choose a particular field of interest to deepen their understanding of a subject, as well as develop their research and academic writing skills. As a pioneer in the field of medical humanities in Africa, and as a musician, Prof. Steve Reid, head of the Primary Health Care Directorate, had been encouraging the availability of various arts-related modules as part of the SSM curriculum. As a dramatherapist, I supervised a module entitled ‘Theatres of the Psyche’. Students were invited to investigate the role of the dramatic arts within a biopsychosocial approach in treating mental illness. The SSM included a practical component in a psychiatric setting, where we presented two storymaking sessions at Valkenberg Hospital, Cape Town. Some reflections from a student are as follows: ‘We get taught a structured mainstream approach, seeing patients for their diseases. This experience helped me to understand a patient is more than their diagnosis, we have to see the person as a whole.’ Hougham[2] wrote that stories can act as containers for our inner lives. By enacting various parts of a story, we come in touch with different parts of ourselves. When we engage with each other in this process, we can also begin to experience each other as whole beings, who constitute more than our designated roles in certain settings – in this case, the role of student, patient and therapist. Another important outcome of this was a raised awareness of interdisciplinarity. At the start of this module, students were invited

to attend a conference hosted by the South African Association of Dramatherapists (SAAD) and UCT’s Department of Occupational Therapy, entitled ‘Healing and social transformation in mental healthcare in South Africa’. This provided an opportunity to engage with a variety of professionals in the field of mental healthcare. Here are the thoughts of one of the students: ‘I had the best time. The whole environment was unique. There was an openness and people were welcoming, not just to each other but also to new ideas. I aim to someday be a part of this sharing of knowledge and skills in order to draw from each other and complement each other’s unique techniques.’ D’Alessandro and Frager[3] concluded in their recent study that theatre and story are effective tools in teaching undergraduate medical students. The dramatherapist believes that ‘Telling a tale enables each of us to know ourselves as someone who has a voice which is worth listening to, someone who can be heard and understood’.[4] It is my hope that the arts and medicine will continue to be partners in the training of knowledgeable, reflective and empathic healthcare professionals. With special thanks to Aisha Najjaar.

Marlize Swanepoel Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, South Africa marlize@wezside.co.za 1. Editorial. Does simulation-based training have a future in Africa?Afr J Health Professions Educ 2014;6(2):117-118. [http://dx.doi.org/10.7196/AJHPE.534] 2. Hougham R. Numinosity, symbol and ritual in the Sesame approach. Dramatherapy 2006;28(2):3-8. 3. D’Alessandro P, Frager G. Theatre: An innovative teaching tool integrated into core undergraduate medical curriculum. Arts & Health: An International Journal for Research, Policy and Practice 2014;6(2):191-204. 4. Gersie A, King N. Storymaking in Education and Therapy. London: Jessica Kingsley, 1990.

Afr J Health Professions Educ 2015;7(1):65. DOI:10.7196/AJHPE.542

May 2015, Vol. 7, No. 1 AJHPE

CPD Questionnaire May 2015 True (A) or false (B): Strategies to include sexual orientation and gender identity in health professions education 1. There are few opportunities for teaching about sexual orientation and gender identity in health professions curricula. An ethical dilemma: A case of student training, intermittent service and impact on service delivery 2. The notion of autonomy accepts that a mentally competent client has the capacity to make an informed decision. Developing an outcomes-based charter to direct teaching and assessment of medical professionalism 3. Attitudes and personal conduct is one of the four main domains under which the attributes of professionalism can be grouped. 4. The results of this study reveal that the UP Charter performs well in its emphasis on research, practice management, and teaching, mentoring and leadership roles of the doctor. The implementation of the Objective Structured Practical Examination (OSPE) method: Students’ and examiners’ experiences 5. The OSPE consists of a circuit of stations that tests a variety of techniques to establish the practical competence of examinees. 6. The OSPE is a useful tool, as it decreases inter-rater reliability when human constraints make it impossible for examiners to only mark the content that they taught. Students’ experiences of inter-professional education through Inter national Classification of Functioning-based activities at a communitybased rehabilitation centre 7. One generic aim of the Bishop Lavis Rehabilitation Centre (BLRC) is to provide an opportunity to observe the community’s rehabilitative needs. Perceptions of physician leadership in Botswana 8. Participants of this study felt that a strong leader should not ask for help. 9. With reference to the research methodology used, inductive content analysis as a research methodology supports qualitative inquiry.

Identity and attribution as lenses to understand the relationship between transition to university and initial academic performance 10. Students who assume an internal locus of causality explain performance with reference to factors such as task difficulty and luck. 11. The literature suggests that race and social class are minor signifiers in university academic performance. The Human Rights Key: An innovative tool for teaching health and human rights in the health sciences 12. Social, political and cultural factors do not contribute towards or limit wellbeing. 13. Key to a human rights approach to health is the development of partnerships with co-operative efforts. Discovering the value of personality types in communication training for pharmacy students 14. In this study, the MBTI personality theory did not hold true for pharmacy students because they are trained in a health environment. 15. The MBTI is used to develop teaching methods aimed at understanding the differences in motivation for learning. A lesson in listening: Is the student voice heard in the rush to incorporate technology into health professions education? 16. Implementation of technology into health professions education can work well if planned effectively. Curriculum challenges faced by rural-origin health science students at South African medical schools 17. A student who feels alienated, alone and unsupported is at high risk for non-persistence or drop-out. 18. Final-year students tend to face more personal challenges than first-year students. Learning approaches used by students in an undergraduate emergency medical care programme 19. Biggs highlighted that learning is not a life-long process. Development of an evaluation matrix for a community-based inter disciplinary health-promotion course 20. Evaluation of community-based courses should include multiple stakeholders.

A maximum of 3 CEUs will be awarded per correctly completed test.

The CPD programme for AJHPE is 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: MDB015/163/02/2015 (Clinical)

May 2015, Vol. 7, No. 1 AJHPE