AJHPE Vol 7, No 2 (2015)

AJHPE

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African Journal of Health Professions Education

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November 2015, Vol. 7, No. 2

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African Journal of Health Professions Education | November 2015, Vol. 7, No. 2 EDITORIAL 146 Has the health professions education research agenda changed in the new millennium?

V Burch REVIEW 147 Optimising cognitive load and usability to improve the impact of e-learning in medical education

M R Davids, M L Halperin, U M E Chikte

SHORT REPORT 153 Rising to the challenge: Training the next generation of clinician scientists for South Africa

B Kramer, Y Veriava, J M Pettifor

RESEARCH 155 Effect of simulated emergency skills training and assessments on the competence and confidence of medical students

I Treadwell 158 Student compliance with indications for intravenous cannulation during clinical learning C Vincent-Lambert, B van Nugteren 161 Implementing and managing community-based education and service learning in undergraduate health sciences programmes: Students’ perspectives

S B Kruger, M M Nel, G J van Zyl 165 Preclinical medical students’ performance in and reflections on integrating procedural and communication skills in a simulated patient consultation

I Treadwell 170 A faculty-led solution to transport-related stress among South African medical students

S Schoeman, G van Zyl, R A Smego (deceased) 176 Nursing students’ perception of simulation as a clinical teaching method in the Cape Town Metropole, South Africa

N Nel, E L Stellenberg 180 Changing students’ moral reasoning ability – is it at all possible?

N Nortjé, K G F Esterhuyse 183 Experiences of medical and pharmacy students’ learning in a shared environment: A qualitative study

D Johnston, P A McInerney, O Fadahun, L P Green-Thompson, S Moch, P Goven Shiba, A Magida 187 Ethical dilemmas experienced by occupational therapy students – the reality

N Nortjé, J de Jongh 190 Promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective

I Ndateba, F Mtshali, S Z Mthembu 194 Dental students’ perceptions of practice management and their career aspirations

S E van der Berg-Cloete, L Snyman, T C Postma, J G White 199 Second-year dental students’ perceptions about a joint basic science curriculum

T C Postma, L Bronkhorst 202 Self-regulation – the key to progress in clinical reasoning?

T C Postma 208 The meaning of being a pharmacist: Considering the professional identity development of first-year pharmacy students

M van Huyssteen, A Bheekie 212 Field trips as an intervention to enhance pharmacy students’ positive perception of a management module in their final year: A pilot study

M J Eksteen, G M Reitsma 216 An exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a South African university

J R Naidoo, S Mthembu 220 Examining the effects of a mindfulness-based professional training module on mindfulness, perceived stress, selfcompassion and self-determination

S Whitesman, R Mash CORRESPONDENCE 224 It is time to balance communitarianism and individualism in South African medical education

L M Campbell, A J Ross, R G MacGregor 226 CPD QUESTIONNAIRE AJHPE is published by the Health and Medical Publishing Group (Pty) Ltd Co registration 2004/0220 32/07, a subsidiary of SAMA | publishing@hmpg.co.za Suites 9 & 10, Lonsdale Building, Gardener Way, Pinelands, 7405 Tel. 021 532 1281 | Cell 072 635 9825 l Letters and articles for publication must be submitted online at www.ajhpe.org.za

EDITORIAL BOARD

EDITOR-IN-CHIEF Vanessa Burch University of Cape Town INTERNATIONAL ADVISORS Deborah Murdoch-Eaton Sheffield University, UK Michelle McLean Bond University, QL, Australia SENIOR DEPUTY EDITORS Juanita Bezuidenhout Stellenbosch University Jose Frantz University of the Western Cape DEPUTY EDITORS Jacqueline van Wyk University of KwaZulu-Natal Julia Blitz Stellenbosch University Michael Rowe University of the Western Cape 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 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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CEO and PUBLISHER Hannah Kikaya Email: hannah.k@hmpg.co.za EDITOR-IN-CHIEF Janet Seggie, BSc (Hons), MD (Birm), FRCP (Lond), FCP (SA) EXECUTIVE EDITOR Bridget Farham, BSc (Hons), PhD, MB ChB MANAGING EDITOR Ingrid Nye TECHNICAL EDITORS Emma Buchanan Paula van der Bijl PRODUCTION MANAGER Emma Jane Couzens DTP & DESIGN Carl Sampson HEAD OF SALES & MARKETING Diane Smith I Tel. 012 481 2069 Email: dianes@hmpg.co.za ONLINE SUPPORT Gertrude Fani I Tel. 072 463 2159 Email: publishing@hmpg.co.za FINANCE Tshepiso Mokoena HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Dr M J Grootboom, Mrs H Kikaya, Prof. E L Mazwai, Dr M Mbokota, Dr G Wolvaardt ISSN 1999-7639

Editorial Has the health professions education research agenda changed in the new millennium?

One of the key mandates of the 21st century is the provision of comprehensive, integrated healthcare to all members of society. For this to become a reality the training needs of all healthcare professionals must be addressed by the research endeavours of health professions educators. So, the key question is, ‘Does the current health professions education research agenda address the training needs of all healthcare professionals?’.

A simple ‘dipstick’ test can be used to provide a broad answer to one aspect of this question. I recently paged through the latest editions of 4 prestigious health professions education (HPE) journals, including Medical Education, Medical Teacher, Academic Medicine and Advances in Health Sciences Education, and found that only 8 of 51 research reports (16%) focused on the training needs of healthcare professionals other than undergraduate and postgraduate medical trainees. While this crude audit has many limitations, it does suggest that the training of medical doctors continues to dominate the HPE research agenda despite the global call for transformation of the training of health professionals, as outlined in the widely cited Lancet Commission published in 2010.[1] Does the African Journal of Health Professions Education (AJHPE) suffer from the same malady or are the education needs of a broader range of health professions being addressed in this journal? The current edition of AJHPE contains only 3 publications of a total of 18 articles (17%) that focus on the training of medical doctors. The other 15 publications (83%) address the education needs of 9 other healthcare professions, including nursing, dentistry, physiotherapy, occupational therapy, emergency medical services, dietetics, psychology, optometry and pharmacy. This finding demonstrates one of the key purposes of the journal – to provide a common platform for the dissemination of information addressing the education needs of all healthcare professionals.

Another aspect of the question posed at the outset of this editorial is whether the education needs of HPE communities of practice, which vary by geographical location, language of instruction, ethnic traditions and beliefs and many other contextual factors, are being addressed. Such factors significantly influence the design and delivery of education programmes for healthcare practitioners. While all these factors are important, the geographical location of the authors and their work is an easy way of obtaining a bird’s eye view of the HPE research landscape. Of the 51 pub­ lications included in the 4 journals already mentioned, 37 articles come from North America, 10 from Europe and the UK, and 4 from the Pacific rim, specifically Australia, Korea and Hong Kong. The absence of a single article from any of the BRICS countries (Brazil, Russia, India, China, South Africa) is striking. Once again, a ‘spot check’ has many limitations, but the annual sprinkling of a few articles from 5 countries that account for 40% of the global population of 3 billion people, cover more than a quarter of the world’s land area over 3 continents and 25% of the global GDP,[2] has to raise the level of response – from concern to one of action.

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This challenge can be addressed by finding ways of supporting the process of HPE research capacity in developing countries rather than trying to establish why these countries have such limited visibility in prestigious journals. A large US-funded HPE capacity development project involving more than 10 HPE institutions in sub-Saharan Africa, the Medical Education Partnership Initiative (MEPI),[3] has yielded a number of worthy publications, including a supplement published in Academic Medicine in 2014.[4] The question, however, is whether the success of these African institutions can be independently sustained and locally replicated in the long term. Building long-term HPE research and development partnerships between MEPI-funded institutions and the many other unfunded HPE institutions in sub-Saharan Africa would be an indicator of real success, i.e. large-scale continental transformation initiated by small pockets of excellence.

In addition to HPE capacity development projects in Africa, journal editors can, and do, play an important role in advancing the scholarship of HPE by providing publication opportunities for emerging researchers. This approach has been adopted by journals such as Medical Education (see the section ‘Really Good Stuff ’) and Academic Medicine (see the section ‘Short Report’). This practice has also been adopted by AJHPE; short reports of <1 500 words, including 1 table or figure and 5 references, appear in this edition of the journal. This category of research publications specifically caters for: (i) work done in single centres; and/or (ii) studies that include a small number of participants; and/or (iii) early innovative work with limited evaluation of impact. This initiative aims to expand the publication footprint of AJHPE by including more work from HPE institutions beyond the borders of South Africa.

In closing, the editorial team would like to wish all our readers well for 2016 and we look forward to receiving more manuscripts from our colleagues in South Africa and those further afield in the rest of subSaharan Africa. As one of my colleagues would say, Ningene kakuhle kunyaka ka – 2016.

Vanessa Burch Editor-in-Chief African Journal of Health Professions Education vanessa.burch@uct.ac.za 1. Frenk J, Chen L, Bhutta Z, Cohen J, Crisp C, Evans T. Health professions for the new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958. [http://dx.doi. org/10.1016/S0140-6736(10)61854-5] 2. Population statistics for BRICS countries. http://globalsherpa.org/bric-countries-brics/ (accessed 10 November 2015).

3. Medical Education Partnership Initiative. http://www.mepinetwork.org (accessed 10 November 2015).

4. Association of American Medical Colleges. The Medical Education Partnership Initiative: Investing in medical education in sub-Saharan Africa. Academic Medicine 2014;89(suppl 8):S1-S116. [http://dx.doi.org/10.1097/ACM.0000000000000357]

Afr J Health Professions Educ 2015;7(2):146. DOI:10.7196/AJHPE.704

Review Research Optimising cognitive load and usability to improve the impact of e-learning in medical education M R Davids,1 MB ChB, FCP (SA), MMed (Int Med), PhD; M L Halperin,2 BSc (Biochemistry), MDCM, FRCP(C), MD; U M E Chikte,3 BChD, DHSM, MDent, MSc, PhD Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

1 2

Emeritus Professor, Division of Nephrology, Li Ka Shing Knowledge Institute, St Michael’s Hospital and University of Toronto, Canada Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

3

Corresponding author: M R Davids (mrd@sun.ac.za)

E-learning has the potential to support the development of expertise in clinical reasoning by being able to provide students with interactive learning experiences, exposure to multiple cases, and opportunities for deliberate practice with tailored feedback. This review focuses on two important but underappreciated factors necessary for successful e-learning, i.e. the management of the learner’s cognitive load and the usability of the technology interface.

Cognitive load theory views learning as involving active processing of information by working memory via separate visual and auditory channels.

This system is of very limited capacity and any cognitive load that does not directly contribute to learning is considered extraneous and likely to impede learning. Researchers in cognitive load theory have provided evidence-based instructional design principles to reduce extraneous cognitive load and better manage the cognitive processing necessary for learning.

Usability is a concept from the field of human-computer interaction which describes how easy technology interfaces are to use, and is routinely evaluated and optimised in the software development industry. This is seldom the case when e-learning resources are developed, especially in the area of medical education. Poor usability limits the potential benefit of educational resources, as learners experience difficulties with the technology interface while simultaneously dealing with the challenges of the content presented. Practitioners in the field of human-computer interaction have provided guidelines and methods for evaluating and optimising the usability of e-learning materials.

The fields of cognitive load theory and human-computer interaction share a common goal in striving to reduce extraneous cognitive load. The load induced by poor usability of e-learning materials can be viewed as a specific component of extraneous cognitive load, adding to any load resulting from poor instructional design. The guidelines from these two fields are complementary and, if correctly implemented, may substantially improve the impact of our e-learning resources on the development of the clinical reasoning skills of students.

Afr J Health Professions Educ 2015;7(2):147-152. DOI:10.7196/AJHPE.569

Clinical reasoning ability is central to clinical competence as it allows medical practitioners to evaluate patients and their test results in order to make accurate diagnoses and implement appropriate treatment.[1] The development of expertise in clinical reasoning may be facilitated through active learning and practice with authentic cases. E-learning has the potential to support this process by providing students with interactive learning experiences, exposure to multiple cases, and opportunities for deliberate practice with tailored feedback.

Creative educators use animation and simulation to build innovative learning resources. The available technology makes it possible to offer personalised instruction, collaboration and an engaging, even immersive, learning experience.[2] Simulations allow inexperienced trainees to practise their clinical reasoning skills on virtual patients without exposing real patients to the possibility of harm, and can provide exposure to a variety of clinical presentations and uncommon medical conditions. Errors in managing these virtual patients may be allowed and provide valuable learning opportunities.

Developing innovative e-learning materials can, however, be very time consuming and expensive. For example, a survey published in 2007 on the development of computer-based virtual patients at medical schools in the USA and Canada revealed that each took an average of 16.6 months to complete and 85% cost >USD10 000 (ZAR120 100).[3] This level of investment of time and money needs to be justified by the educational impact of the

resources developed, especially in under-resourced environments such as African tertiary education institutions.

There are many factors that must be in place to ensure successful e-learning.[4] This article highlights two critically important but under-appreciated factors, i.e. the management of the learner’s cognitive load and the usability of the computer interface. The sections that follow briefly discuss: (i) development of expertise in clinical reasoning; (ii) cognitive load theory and its relevance to e-learning; and (iii) importance of the usability of computer interfaces.

Developing expertise in clinical reasoning

Learning requires alterations in long-term memory. The major mechanisms involved are the acquisition and automation of knowledge schemas.[5] In the context of clinical medicine, schemas are sometimes also referred to as ‘illness scripts’.[6] These are cognitive constructs or ‘mental models’ for organising and storing information.

The critical role of long-term memory in intellectual performance started emerging with the publication in the 1960s of studies on chess players.[7] After a brief exposure to a typical mid-game position, expert chess players were much better than novices in their ability to recall the exact positions of the pieces. However, when the same pieces were randomly distributed on the board, there was no difference between experts and novices in recalling the positions of the pieces.[8] Chess experts do not see a position as isolated pieces, but as configurations of pieces and squares, most of which they have seen many times before. These configurations are stored as ‘chunks’ or

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Review schemas, and it is estimated that chess experts have between 10 000 and 100 000 such configurations stored in their long-term memory.

Similarly, medical experts appear to solve most clinical problems by pattern recognition, without resorting to ana­lytical, pathophysiological reasoning.[9] They are able to do this, with good diagnostic accuracy, by drawing on an extensive database of schemas or illness scripts stored in their long-term memory. Many studies on noviceexpert differences indicate that expertise is the result of the acquisition of a large fund of domainspecific knowledge that is well organised and easily retrieved when needed.[10] Deliberate practice over an extended period of time produces a high level of automation of these schemas[11] so that their use no longer requires conscious processing and makes minimal demands on the limited resources of working memory. This is how the expert clinician is able to make diagnoses rapidly, accurately and effortlessly. However, when problems are unusual or complex, the expert is able to shift from pattern recognition to analytical reasoning and bring to bear an extensive store of basic science knowledge to address the problem.[12] This is often required in disciplines such as anaesthesiology, intensive care medicine and nephrology, which are rooted in the basic sciences.[12] Expertise in clinical reasoning is very case specific.[13] Our challenge as teachers is to help students develop expertise that can be effectively applied to the diagnosis and management of different – but related – cases that they encounter later. Such transfer of expertise is very difficult to achieve,[13,14] but may be facilitated by ensuring active learning and creating opportunities for ‘deliberate practice’[11] with carefully selected and sequenced examples. Multiple examples of cases or clinical problems allow learners to encounter key concepts in a variety of contexts.

This facilitates the abstraction of the underlying concepts rather than merely focusing on the surface features of clinical problems, and improves the transfer of clinical reasoning ability from one problem to another.[1] E-learning offers the possibility of fostering deep learning and the transfer of expertise in clinical reasoning by being able to provide students with interactive learning experiences, exposure to multiple cases, including cases seldom encountered during their clinical rota­ tions, and opportunities for deliberate practice with immediate feedback.

There are many factors that must be in place to ensure successful e-learning[4] and exploit the

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educational potential of innovative e-learning resources. These include ensuring institutional buy-in, ensuring that appropriate hardware and software are available, and providing skills training and technical and administrative support. There must be appropriate integration of e-learning into the curriculum, ensuring that assessments include the e-learning material, and a blended learning approach should be used where possible.

The following sections highlight the importance of managing the learner’s cognitive load and optimising the usability of the computer interface when implementing e-learning. These factors may have a major influence on the benefit derived from the e-learning resources we employ to develop the clinical reasoning skills of our students.

Managing cognitive load to promote learning

Cognitive load theory builds on well-established models of human memory that include the sub­ systems of sensory memory, working memory and long-term memory.[15] While long-term memory appears to have an unlimited capacity, working memory has a very limited capacity and can hold and process only a few discrete elements at any given time.[16] Sweller’s cognitive load theory[17] and Mayer’s cognitive theory of multimedia learning[18] are based on a model of human cognitive architecture that views learning as involving the active processing of information by working memory via separate visual and auditory channels (Fig. 1).

This system for dealing with new information is of very limited capacity and any cognitive load that does not directly contribute to learning is considered extraneous and likely to impede learning.

Overloading the limited capacity of working memory is more likely to occur when the content to be learned is difficult and presents a high

Multimedia presentation

Sensory memory

Words

Ears

Pictures

Eyes

intrinsic cognitive load.[19] Intrinsic cognitive load refers to the essential processing required to understand the learning material. When the material consists of multiple interacting elements of information, the intrinsic cognitive load will be high and learners therefore experience it as difficult. Because of the interaction the elements cannot be learned in isolation or sequentially, but must be assimilated simultaneously for learning to occur.[19] The topic of metabolic acidosis, for example, is difficult because there are many interacting elements that operate simultaneously. Students have to appreciate that metabolic acidosis may be caused by a gain of acid or the loss of sodium bicarbonate. They must also appreciate the role of the following: the extracellular fluid volume in determining the bicarbonate concentration; buffer systems in ameliorating the effects of an acid load; the kidney in excreting acid and generating new bicarbonate; and the respiratory system, which compensates for the acidosis by increasing ventilation.

In contrast to the example of metabolic aci­ dosis, some content may also contain many elements, but because of a low level of interactivity these elements can be learned in isolation or sequentially. The intrinsic cognitive load which it presents is low, and the content is therefore not experienced as difficult. For example, learning where hormones are produced could involve a long list of hormones and their sites of origin, but each of these unrelated hormone-origin pairs has little interaction with the successful learning of any other pair. Learning that insulin is produced by the pancreas, for instance, can be done in isolation and without reference to any other hormone and its site of origin.

The number of elements and degree of interactivity in a particular piece of learning material can only be an estimate as it varies according to the level of expertise of an individual.

Long-term memory

Working memory selecting words selecting images

Sound

Images

organising words organising images

Verbal model

integrating

Prior knowledge

Pictorial model

Fig. 1. The cognitive theory of multimedia learning. Sensory memory holds an exact copy of what was presented for <0.25 second, working memory holds a more processed version for <30 seconds and can process only a few items at any one time, and long-term memory has virtually unlimited capacity, holding an individual’s entire store of knowledge for long periods of time. From Mayer RE,[20] with permission.

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Review Research Therefore, whether material is experienced as difficult or not depends mainly on the presence, sophistication and automation of pre-existing schemas in the long-term memory of the individual.

There is a growing body of evidence support­ ing the idea that learning materials should be designed consistent with principles of cognitive load theory. Research-based design principles have been proposed which are aimed at reducing extraneous cognitive load, managing essential processing, and fostering generative processing during learning. These principles are listed in Table 1 and discussed in the sections below.

Reducing extraneous processing

Extraneous cognitive load is caused by poor instructional design and results in processing being required that does not contribute to schema acquisition or automation. Methods of presentation that reduce extraneous cognitive load free up working memory and facilitate learning. Mayer[20] has recommended reducing extraneous load by applying the coherence principle, which states that all irrelevant material should be eliminated; the signalling principle, which involves highlighting essential material; and the spatial contiguity principle, which involves placing printed words near the corresponding graphics. These principles are aimed at minimising the splitting of the learners’ attention between multiple sources of information, and avoiding the presentation of redundant or irrelevant information.[5] For example, if a set of images illustrating the functions of the kidneys is physically separated from the corresponding explanatory text, the learner needs to scan back and forth to mentally integrate these two sources of information.

Restructuring the information so that the explanatory text is close to, or even inserted into, each image eliminates the need for mental integration and reduces cognitive load.

Managing essential processing

Essential processing involves selecting relevant information and representing it in working memory. The complexity of the material and the existing expertise of the learner determine the intrinsic cognitive load related to this part of the learning process. Intrinsic cognitive load can be managed by applying research-based design principles. The pretraining principle states that people learn better from a multimedia lesson when they are already familiar with the

Table 1. Principles for the design of e-learning materials from Mayer’s cognitive theory of multimedia learning[20] Reducing extraneous processing

Coherence principle: eliminate all extraneous material Signalling principle: highlight essential material Contiguity principle: place printed words near corresponding graphics

Managing essential processing

Pretraining principle: provide pretraining in the names and characteristics of key concepts Segmenting principle: break lessons into learner-controlled segments Modality principle: present words in spoken form rather than as text to be read

Fostering generative processing

Multimedia principle: use words and pictures rather than words alone Personalisation principle: present words in a conversational style Voice principle: use a human voice rather than a machine voice

key components and concepts. Novice learners should therefore receive pretraining in the names and functions of each major component of a new lesson. The segmenting principle states that people learn better when a large lesson is broken down into smaller, learner-paced segments. The navigation of the lesson should therefore be under the control of the learner. The modality principle states that the words in a multimedia lesson should be delivered via narration rather than being printed, thereby shifting information from a potentially overloaded visual channel onto the auditory channel.

Fostering generative processing

Generative processing is aimed at making sense of the material during learning and involves organising and integrating pictures and words and information from long-term memory. Three design principles are helpful for increasing motivation and engagement, thereby promoting generative processing. The multimedia principle is that people learn better from words and pictures than from words alone. For example, instead of only presenting a block of text explaining how the kidney works, add a series of illustrations.

The personalisation principle is that people are more engaged and learn better when words are delivered in conversational language rather than in more formal language. For example, it is better to refer to ‘your kidney’ rather than ‘the kidney’. The voice principle is that people learn better from multimedia lessons when the narration uses a human voice rather than a computer-generated one.

The advances in cognitive science summarised above provide useful guidance for designing effective e-learning resources that can support the development of students’ clinical reasoning skills.

The implementation of these design principles has been tested in multiple experiments and

shown to have a significant positive impact on learning, with medium to large effect sizes.[20]

Improving the usability of computer interfaces

Usability is a concept from the discipline of human-computer interaction that describes how easy it is to use technology interfaces.[21] Interfaces should be designed to be intuitive and self-evident, so that even inexperienced users can accomplish tasks successfully. The International Standard, ISO 9241-11, formally defines usability as the ‘extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use’.[22] Design approaches that evaluate and optimise usability are common in the field of software development, but this is still seldom the case with e-learning, especially in the area of medical education.[23] Studies on e-learning interventions in the health sciences rarely describe usability evaluation that has been conducted at an early stage of the development process, and usability is usually not even mentioned as a component of the final evaluation. It has been suggested that journals should encourage the authors of e-learning articles to report on usability and share the important lessons learnt, thereby helping colleagues to avoid costly mistakes in the future.[23] High usability of e-learning materials is required to ensure the maximum educational impact, especially when the material to be learnt is complex.[19] Poor usability limits the potential benefit obtained from e-learning resources[23,24] by imposing an extraneous cognitive load, as users struggle with the interface and challenges of the content presented. We observed this with an interactive simulation we developed for improving clinical reasoning in the area of electrolyte

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Review disorders.[25] Formal usability evaluation revealed that serious usability problems rendered the resource unusable for many participants.[26] Some researchers have found significant learning effects from optimising the usability of learning materials.[27] This is most likely to be seen with novice learners who experience the content as presenting a high intrinsic cognitive load and would therefore be more sensitive to any extraneous load imposed by poor usability.[17] Other researchers have reported improvements in efficiency, satisfaction or motivation.[24,28,29] These effects are important in the light of the high dropout rate from e-learning courses.[30] Motivated and self-regulated learners are more likely to persist and succeed in e-learning environments, and by optimising usability one can make an important contribution to their satisfaction and motivation.

An example of a usability problem and how it might be addressed is presented in Fig. 2.

The two main approaches to usability evaluation are ‘usability inspection’ and ‘user testing’.[33,34] Usability inspection involves a process where experts evaluate the application against established design principles and includes methods such as heuristic evaluation, cognitive walkthroughs, guideline review and consistency inspection.[33] Cognitive walkthroughs involve evaluators doing a step-by-step execution of common tasks, taking into account a typical user’s likely goals and knowledge. They focus on the differences between the user’s expectations and likely actions, and the steps required by the interface. Guideline reviews check whether an interface conforms to a set of design guidelines, such as an industry standard or corporate style guide. Consistency inspection is a methodical review for consistency in design throughout an application, including the graphics, text and the interaction or navigation style.

Heuristic evaluation is the most widely used inspection method and involves experts evaluating a technology interface against a set of heuristics, or principles of good interface design[35] (Table 2). It provides an efficient alternative to testing with representative endusers[31] and can usually be conducted in less time, and at much less expense, than user testing. A group of inspectors is required, as the average problem detection rate of individual inspectors is generally low and each tends to uncover a different set of usability problems.[36] Inspectors will usually categorise the problems detected with regard to their severity and may also suggest solutions to the problems identified.

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Empirical user testing involves the recruitment of typical end-users and studying their interaction with the application. This approach is often considered to have better validity and a greater impact on product development than inspection methods.[34,38] Evaluations may be conducted in sophisticated usability laboratories and informal settings using paper prototypes and think-aloud protocols. Selecting which usability measures to use can be difficult. There is no single global measure of usability. Some measures are subjective and others objective; all have their own cost and time requirements, and examine a particular aspect of usability. The objective measures include parameters such as successful task completion and error rates, while subjective

measures include parameters such as satisfaction and perceived workload[39] and often make use of standardised questionnaires.

Recently, there has been an increasing trend to use a broader range of measures to evaluate the user experience. This includes measures such as engagement, motivation, aesthetics, and fun.[29,30] The affective features of instructional messages can influence the level of learner motivation and engagement in deep processing. We should therefore consider incorporating instructional design features aimed at priming motivation, while being careful not to overload the learner’s working memory.[40] Our own experience[25,26,31,32] has illustrated how clinician-teachers who are not usability

Table 2. Principles of good interface design. These commonly used heuristics are from Nielsen,[35] with the last item from Karat et al.[37] Heuristic

Descriptor

1.

Visibility of system status; feedback

Keep users informed through timely appropriate feedback. They should always know where they are, which actions can be taken and how these actions can be performed.

2.

Match with the real world – language, conventions

Speak the users’ language, with familiar words, phrases and concepts. Follow real-world conventions, making information appear in a natural and logical order.

3.

Consistency and conformity to standards

Words, situations and actions mean the same thing; application uses commonly accepted platform conventions and conforms to user expectations.

4.

Minimise memory load; recognition rather than recall

Make objects, actions, and options visible. The user should not have to remember information from one part of the application to another. Instructions should be visible or easily retrievable.

5.

Aesthetic and minimalistic design

No irrelevant information as it competes with relevant information and diminishes its relative visibility.

Animation and transitions should be used sparingly.

6.

Help and documentation

It is better if the system can be used without documentation. If required it should be concise, easy to search and task centred.

7.

User control and freedom

The user can control the direction and pace of the application. Clearly marked exits are available if they take incorrect options by mistake. The application supports Undo and Redo.

8.

Flexibility and efficiency of use

Users can modify the application to suit their individual capabilities and needs, e.g. by using shortcuts.

9.

Error prevention and tolerance

Careful design to prevent errors occurring. Despite user errors, the intended result may still be achieved by error correction or good error management.

10.

Help users recognise, diagnose and recover from errors

Error messages should be expressed in plain language (no codes), precisely indicate the problem, and constructively suggest a solution.

11.

Intuitive visual layout

Position elements on screen to be easily perceived and understood, and visually attractive.

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Review Research that included testing with end-users[26] and inspection by experts against principles of good design.[31] Serious usability problems were identified, which limited the educational impact of the resource. User testing and expert evaluation each detected problems that were missed with the other method. We also observed a striking disconnect between objective usability measures and self-reported data. The usability problems were corrected in a subsequent redesign and resulted in substantial improvements in usability as assessed in a randomised trial that compared the original with the revised version.[32] The question of how many users are required for an evaluation is important because each additional user adds to the cost and the time required. Nielsen[41] has suggested that 4 - 5 users are sufficient, as they will uncover 80% of the usability problems with a technology interface. This well-known ‘five users are enough’ approach assumes that a formative evaluation is being conducted where several iterations of testing and redesign are envisaged. However, when the application is complex or when testing is done after the most obvious problems are already fixed, the probability of detecting each usability problem decreases and more users may be required.[26,42] To date, there has been surprisingly limited interaction between usability practitioners and researchers in the field of cognitive load theory. A recent review[43] reported that cognitive load theory concepts were mentioned in very few of the citations in the Guide to Computing Literature[44] database.

The authors of this review point out that the two fields have much in common, notably a strong focus on the reduction of extraneous cognitive load. They propose that the load induced by poor usability of e-learning interfaces be viewed as a specific component of extraneous cognitive load, adding to the load resulting from poor instructional design.

Conclusions and recommendations for e-learning design

Fig. 2. An example of a usability problem. The ‘hidden’ laboratory data panel displays information essential for the assessment of the case presented. Upon clicking the tab at the side of the screen (A, red arrow) it slides open (B). This was completely missed by several users who then entered the treatment simulation which followed and attempted to treat their patient without having accessed this important information.

When open, the panel obscures other on-screen information and remains open even when navigating to another slide. The tab has to be clicked again to close the panel.

This usability problem was corrected in a subsequent redesign (C). The sliding panel has been completely eliminated and all the information is now in full view in the Patient Data panel on the left of the slide. From Davids MR, et al.[26,31,32]

experts can set about improving the usability of the resources they develop and provide a practical example for teachers in medical education and other areas. We developed a multimedia e-learning resource for electrolyte and acid-base disorders,[25] and then conducted a usability evaluation

The guidelines that the fields of cognitive load theory and humancomputer interaction have provided are complementary. Both fields have a strong focus on reducing extraneous cognitive load. Applying evidencebased design principles to manage cognitive load and optimising usability is essential to improve the educational impact of our e-learning resources.

This is especially relevant with innovative and interactive multimedia resources, which are very costly and time consuming to develop but have great potential in facilitating the development of the clinical reasoning skills of our students.

Usability evaluation is critical and should form a routine part of the development and implementation of e-learning materials, modules or programmes. Failing to do this may result in the implementation of resources that are unusable for many learners. It is advisable to start with the earliest versions of the resource, ideally at the prototype stage, when making changes is easier and much less costly. An iterative approach should be followed, with several cycles of testing and redesign. Heuristic evaluation by experts should be used first and, once the obvious problems have been identified and fixed, followed by testing with real users. User testing should always include the study of objective usability measures and not rely only on self-reported measures of user satisfaction.

References 1. Norman G. Research in clinical reasoning: Past history and current trends. Med Educ 2005;39:418-427.

2. Ellaway R, Masters K. AMEE Guide 32: e-Learning in medical education Part 1: Learning, teaching and assessment. Med Teach 2008;30:455-473. [http://dx.doi.org/10.1080/01421590802108331] 3. Huang G, Reynolds R, Candler C. Virtual patient simulation at US and Canadian medical schools. Acad Med 2007;82:446-451.

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Review Research 4. Childs S, Blenkinsopp E, Hall A, Walton G. Effective e‐learning for health professionals and students – barriers and their solutions. A systematic review of the literature – findings from the HeXL project. Health Info Libr J 2005;22:20-32.

5. Sweller J. Implications of cognitive load theory for multimedia learning. In: Mayer RE, ed. The Cambridge Handbook of Multimedia Learning. New York, NY: Cambridge University Press, 2005:19-30.

6. Barrows HS, Feltovich PJ. The clinical reasoning process. Med Educ 1987;21:86-91.

7. de Groot AD. Thought and Choice in Chess. 2nd ed. The Hague: Mouton Publishers, 1978.

8. Chase WH, Simon HA. Perception in chess. Cognit Psychol 1973;4:55-81.

9. Eva KW, Norman GR, Neville AJ, Wood TJ, Brooks LR. Expert-novice differences in memory: A reformulation.

Teach Learn Med 2002;14:257-263.

10. Ericsson KA, Kintsch W. Long-term working memory. Psychol Rev 1995;102:211-245.

11. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:S70-S81.

12. Norman GR, Trott AL, Brooks LR, Smith EKM. Cognitive differences in clinical reasoning related to postgraduate training. Teach Learn Med 1994;6:114-120.

13. Eva KW, Neville AJ, Norman GR. Exploring the etiology of content specificity: Factors influencing analogic transfer and problem solving. Acad Med 1998;73:S1-S5.

14. Elstein AS, Shulman LS, Sprafka SA. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA: Harvard University Press, 1978.

15. Young JQ, van Merrienboer J, Durning S, ten Cate O. Cognitive load theory: Implications for medical education: AMEE Guide No. 86. Med Teach 2014;36:371-384. [http://dx.doi.org/10.3109/0142159X.2014.889290] 16. Simon HA. How big is a chunk? Science 1974;183:482-488.

17. Sweller J, van Merrienboer JJG, Paas FGWC. Cognitive architecture and instructional design. Educ Psychol Rev 1998;10:251-296.

18. Mayer RE. Multimedia Learning. Cambridge, UK: Cambridge University Press, 2001.

19. Sweller J. Cognitive load theory, learning difficulty, and instructional design. Learn Instr 1994;4:295-312.

20. Mayer RE. Applying the science of learning to medical education. Med Educ 2010;44:543-549. [http://dx.doi. org/10.1111/j.1365-2923.2010.03624.x] 21. Nielsen J. Usability 101: Introduction to usability. Nielsen Norman Group. 2003. http://www.nngroup.com/ articles/usability-101-introduction-to-usability/ (accessed 31 August 2014).

22. Abran A, Khelifi A, Suryn W, Seffah A. Usability meanings and interpretations in ISO standards. Software Qual J 2003;11:325-338.

23. Sandars J. The importance of usability testing to allow e-learning to reach its potential for medical education.

Educ Prim Care 2010;21:6-8.

24. Zaharias P. Usability in the context of e-learning. Int J Technol Human Interact 2009;5:37-59.

25. Davids MR, Chikte UME, Halperin ML. Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders. Adv Physiol Educ 2011;35:295-306. [http://dx.doi.org/10.1152/advan.00127.2010]

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26. Davids MR, Chikte U, Grimmer-Somers K, Halperin ML. Usability testing of a multimedia e-learning resource for electrolyte and acid-base disorders. Brit J Educ Technol 2014;45:367-381.

27. Avouris NM, Dimitracopoulou A, Daskalaki S, Tselios NK. Evaluation of distance-learning environments: Impact of usability on student performance. International Journal of Educational Telecommunications 2001;7:355-378.

28. Kanuka H, Szabo M. Conducting research on visual design and learning: Pitfalls and promises. Can J Learn Technol 1999;27:105-123.

29. Hancock PA, Pepe AA, Murphy LL. Hedonomics: The power of positive and pleasurable ergonomics. Ergon Des 2005;13:8-14.

30. Zaharias P, Poylymenakou A. Developing a usability evaluation method for e-learning applications: Beyond functional usability. Int J Hum-Comput Interact 2009;25:75-98.

31. Davids MR, Chikte UME, Halperin ML. An efficient approach to improve the usability of e-learning resources: The role of heuristic evaluation. Adv Physiol Educ 2013;37:242-248. [http://dx.doi.org/10.1152/advan.00043.2013] 32. Davids MR, Chikte UM, Halperin ML. Effect of improving the usability of an e-learning resource: A randomized trial. Adv Physiol Educ 2014;38:155-160. [http://dx.doi.org/10.1152/advan.00119.2013] 33. Nielsen J, Mack RL. Usability Inspection Methods. New York: Wiley, 1994.

34. Dumas JS, Salzman MC. Usability assessment methods. Rev Hum Factors Ergon 2006;2:109-140.

35. Nielsen J. 10 Usability heuristics for user interface design. Nielsen Norman Group. 1995. http://www.nngroup. com/articles/ten-usability-heuristics/ (accessed 14 October 2014).

36. Hertzum M, Jacobsen NE. The evaluator effect: A chilling fact about usability evaluation methods. Int J HumComput Interact 2001;13:421-443.

37. Karat C-M, Campbell R, Fiegel T. Comparison of empirical testing and walkthrough methods in user interface evaluation. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. Monterey, CA: ACM, 1992:397-404.

38. Rosenbaum S, Rohn JA, Humburg J. A toolkit for strategic usability: Results from workshops, panels, and surveys.

Proceedings of the SIGCHI conference on Human Factors in Computing Systems. The Hague, The Netherlands: ACM, 2000:337-344.

39. Hornbæk K. Current practice in measuring usability: Challenges to usability studies and research. Int J HumComput St 2006;64:79-102.

40. Mayer RE. Incorporating motivation into multimedia learning. Learn Instr 2014;29:171-173.

41. Nielsen J. How many test users in a usability study? Jakob Nielsen’s Alertbox. 2012. http://www.nngroup.com/ articles/how-many-test-users/ (accessed 1 April 2015).

42. Faulkner L. Beyond the five-user assumption: Benefits of increased sample sizes in usability testing. Behav Res Meth Instrum Comput 2003;35:379-383.

43. Hollender N, Hofmann C, Deneke M, Schmitz B. Integrating cognitive load theory and concepts of humancomputer interaction. Comput Hum Behav 2010;26:1278-1288.

44. Association for Computing Machinery. The ACM Guide to Computing Literature. http://librarians.acm.org/ acm‐guide‐computing‐literature (accessed 18 August 2015).

Short report Rising to the challenge: Training the next generation of clinician scientists for South Africa B Kramer,1 BSc, BSc Hons, PhD; Y Veriava,2 MB BCh, FCP (SA), FRCP (Lond), DSc (Honoris causa); J M Pettifor,1 MB BCh, PhD (Med), FCPaed (SA), MASSAf Health Sciences Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

1

School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

2

Corresponding author: B Kramer (beverley.kramer@wits.ac.za)

Background. A shortage of clinician scientists globally, particularly in the developing world, including Africa and South Africa (SA), is well known and was recently highlighted in a consensus report by the Academy of Science of South Africa. There is a need to find innovative ways to develop and advance clinician scientists in SA. Objective. To provide opportunities for young clinicians to develop research skills through enrolling for a PhD. Method. To address this need in SA, we developed an innovative programme over 2 years in collaboration with the Carnegie Corporation of New York to support and train young specialist clinicians in research as the next generation of clinician scientists, through a full-time PhD programme.

Results. Since initiation of the programme in March 2011, 16 such specialists have been enrolled at intervals in the Fellowship programme, 5 have qualified with PhDs, while a further 3 are expected to qualify shortly. Publications and presentations at congresses have been recorded as well as grant applications.

Discussion. Although the programme is seen as an important initial step in addressing the shortage of clinician scientists, its dependence on donor funding and the lack of a secure career path for clinicians wishing to spend more of their career in research pose problems for the programme’s sustainability. It is hoped that the positive outcomes of this experience will initiate further programmes of this kind at academic institutions and attract the attention of funders and universities in order to sustain and enlarge this initiative.

Afr J Health Professions Educ 2015;7(2):153-154. DOI:10.7196/AJHPE.671

In Africa we are faced with enormous challenges in healthcare that require intensive and high-quality research; yet, there is a lack of clinically trained research scientists and of support for those who do exist. If South Africa (SA) in particular and Africa in general are going to tackle their huge healthcare burdens appropriately, we need well-trained scientists with clinical expertise to lead research endeavours and to train our future clinical researchers.

Because of the ‘serious decline in clinical research activity and capacity’, the Academy of Science of South Africa (ASSAf) examined the state of clinical research and related training in South Africa. In 2009, the report published by ASSAf recommended, among others, ‘stimulating PhD degrees for professional graduates through the widening of the necessary opportunity and support mechanisms’.[1] The recommended target was 500 PhDs to be produced in the clinical research field over the next 10 years.[1] In the USA the MD-PhD pathway appears to be the most prevalent way of training clinician scientists.[2] The federal government through the National Institutes of Health (NIH) is the major funder of such programmes.[3] While the MD-PhD programme has been successful, the postgraduate training of clinicians in research is also showing promising outcomes.[4] A similar programme was established in the UK in 2000 following reports from the Royal College of Physicians and the Academy of Medical Sciences of the United Kingdom.[5] However, this process, while well funded and highly competitive, has had low PhD completion rates.[3] The importance of investment in the development of clinician scientists cannot be overestimated. However, not all governments invest or invest sufficiently in this area. While the ASSAf report[1] recommended ‘raising the Research and Development budget to 2% of the gross domestic product (GDP), of which 20% should be allocated to health research’, as well as other

measures, to date this is only slowly translating into funding for capacity development in the clinical sciences in SA. In 2009, the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, SA, supported by the Carnegie Corporation of New York, chose to initiate a programme around the development of appropriately skilled academic clinicians, of which the clinician scientist was an integral part.

This article describes the setting up of the programme, the aim of which is to provide opportunities for young clinicians to develop research skills through enrolling for a PhD.

Methods

On the basis of funding from the Carnegie Corporation of New York, the Faculty of Health Sciences formalised the ‘Academic Medicine Clinician Scientist PhD Programme’ within the Health Sciences Research Office and appointed a Director of the programme to provide oversight and mentorship to the Fellows.

Applicants are required to have a medical degree and a specialist qualification (MMed degree). The Fellowship is of 2 years’ duration (restricted owing to funding), during which period Fellows are expected to complete their PhD − ready for submission for examination. Fellows select their own field of research and supervisor/s in one of the well-established research niches in the Faculty. As part of the Fellowship the candidates have to attend courses, e.g. on research methodology, biostatistics, scientific writing, research ethics, curriculum design and student assessment. So as to allow for full-time research activities, the Fellows do not participate in routine clinical service delivery. Once the PhD degree has been attained, funding is also provided towards running expenses for postdoctoral research activities to encourage the setting up of a research niche by the Fellow.

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Short report It is critical to adequately support the Fellows financially during the 2-year period of their fellowship. Therefore, each Fellow is provided with a tax-free stipend approximately equivalent to that which they would have earned in their clinical post, but without overtime remuneration, medical aid and pension contributions. As most SA academic clinicians are employed by the Provincial Government, it has been important to negotiate with the authorities to allow the relevant Fellow/s to take a 2-year leave of absence from their posts to allow them to return to their clinical position on completion of their fellowships.

Results

To date we have enrolled 16 Fellows into the programme in 4 cohorts of 4 Fellows each per annum. The 16 Fellows were ethnically diverse â&#x2C6;&#x2019; 7 black, 6 Indian, 2 white and 1 coloured. Fellows accepted into the programme were mainly of SA origin (14 out of 16). Thirteen of the 16 Fellows were females. Fields of research have been generally well distributed over the disciplines within clinical medicine, thus establishing niche areas where research in these specific fields can grow in the future.

While the programme is in its infancy, we believe the outcomes have been substantial. The first cohort of 4 Fellows completed their Fellowships in 2013 and graduated in the same year, thus completing their degree in the minimum 2-year time period. All 4 graduates have returned to their clinical departments in the academic hospitals. The second cohort of 4 Fellows was due to complete in July 2014 (only 1 has graduated within the 2 years, the others should be submitting their theses shortly), while the third and fourth cohorts are still in the early stages of their research.

Publication outputs with regard to cohort 1 have been very encouraging (11 publications), as well as several presentations at local and international congresses. Publication output from the second cohort has been less substantial to date. In addition, 3 of the Fellows from cohort 1 were awarded a total of 4 awards for their presentations at national congresses, and thus far 1 Fellow from cohort 2 has been awarded for a presentation at a congress. One Fellow from cohort 2 was appointed as Assistant Dean for Teaching and Learning. Two of the Fellows have been awarded substantial grants by an external/corporate foundation. A total of 81 research courses have been attended by the first 8 Fellows, indicating the perceived need for such formal training during the PhD programme.

Discussion

Although in its infancy in comparison with programmes in the USA and UK, the Wits Academic Medicine Clinician Scientist Programme was successfully initiated to meet the need voiced by the SA Minister of Health, the SA Medical Research Council and ASSAf[1] to increase the number of clinician scientists in the country.

The programme has demonstrated the possibility of training qualified medical specialists in research and academic skills, with the outcome of a completed PhD in a minimum of 2 years. We acknowledge, however, that this period is extremely demanding and inappropriately short when compared with other programmes such as the NIH Mentored Research Scientists Development Award (K01) programme, which provides protected time of 3 - 5 years for career development in clinical sciences.[6] Kosik et al.[4] undertook a systematic review of the literature to identify the best models for clinician scientist training. Using outcome measures such as publications and/or awarding of grants, the authors identified 13 programmes in 9 studies. Of the programmes surveyed, the Medical Scientist Training Programme in the USA proved to be the most successful model, with 83% of graduates entering a career in academia and 78% receiving major grants,[4] although this positive assessment is not shared by

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all. Kosik et al.[4] also suggest that training following specialisation through postgraduate programmes showed promising outcomes. The average time to complete the MD-PhD in 24 programmes in the USA was 8.0Âą0.4 years.[2] In the SA context, as in other developing countries, where doctors are sorely needed following graduation, training clinician scientists at the postgraduate level is the financially more viable and faster option.

The gains already experienced from this new programme have been substantial. It has firmly established the opportunity in the Faculty for young clinicians wishing to obtain a PhD. Furthermore, clinical publications and conference proceedings have emanated from the programme. We hope the programme will have a positive effect on the retention of young staff, as on completion of their Fellowships the Fellows are expected to return to their original departments and are given research funding for a year postPhD to encourage the development of a research nidus in their disciplines.

The sustainability of this programme is of concern. The funding required to maintain it is higher than that of the average PhD programme, as it has to provide a stipend which is commensurate with the age and qualifications of the Fellows.

The lack of suitable funders locally may be a barrier to continuing and extending the programme. In addition, the lack of a defined clinician researcher career path in academic medicine in SA is an additional barrier to continuance of the programme.

In this regard, there is a need for the University to accept that it has the responsibility to fund research and support staff positions in the clinical disciplines.

While it is premature to assess the impact of this programme, its influence will be tracked over time. The challenges faced by clinicians in an African setting, through our quadruple burden of disease and the resulting heavy clinical service loads, are very different from those faced by clinicians in developed countries, and impact on the training of our young clinicians. Therefore, to enable our clinician scientists to achieve the relevant research training in this difficult arena, a structured programme ensuring protected time is imperative.

Conclusion

An innovative, structured programme that ensures protected time for undertaking research has been set up for the training of clinician scientists at our institution. This programme shows promising outcomes, which may lead to the training of a pool of clinician scientists for Africa.

Acknowledgements. The authors wish to acknowledge the support of the Carnegie Corporation of New York, without which the initiation of this programme would not have been possible. In addition, two past Deputy Vice-Chancellors, Profs Bellinda Bozzoli and Helen Laburn at our institution, must be acknowledged for their contributions and valuable insight into the initiation of this programme. Ethics clearance for undertaking this study was approved by the Human Research Ethics Committee of the University of the Witwatersrand (HREC M140701).

Conflict of interest. The authors declare that funding was received for the programme from the Carnegie Corporation of New York.

References 1. Mayosi BM, Dhai A, Folb P, et al. Revitalising Clinical Research in South Africa: A Study on Clinical Research and Related Training. Pretoria: Academy of Science of South Africa, 2009.

2. Brass LF, Akabas MH, Burnley LD, et al. Are MD-Ph.D programs meeting their goals? An analysis of career choices made by graduates of 24 MD-PhD programs. Acad Med 2010;85(4):692-701. [http://dx.doi.org/10.1097/ ACM.0b013e3181d3ca17] 3. Stewart GW. An MBPhD programme in the UK: The UCL experience. Clin Med 2012;12(6):526-529. [http:// dx.doi.org/10.7861clinmedicine,12-6-526] 4. Kosik RO, Tran DT, Pei-Chen Fan A, et al. Physician scientist training in the United States: A survey of the current literature. Eval Health Prof 2014;1-18. [http://dx.doi.org/10.1177/0163278714527290] 5. Turnbridge M. Monitoring the clinicain scientist scheme. Clin Med 2004;4(2):141-143. [http://dx.doi.org/10.7861/ clinmedicine.4-2-141] 6. Juve AM, Kirsch JR, Swide C. Training intensivists and clinician-scientists for the 21st century: The Oregon Scholars Program. J Grad Med Educ 2010;2(4):585-588. [http://dx.doi.org/10.4300/JGME-D-10-000871]

Research Effect of simulated emergency skills training and assessments on the competence and confidence of medical students I Treadwell, DCur, HED Skills Centre, Sefako Makgatho Health Sciences University (formerly Medunsa Campus of the University of Limpopo), Pretoria, South Africa Corresponding author: I Treadwell (ina.treadwell@gmail.com)

Background. At Medunsa, Pretoria, South Africa, the training of final-year medical students includes the management of simulations that incorporate, inter alia, the following emergency skills: cardiopulmonary resuscitation (CPR), defibrillation, airway suctioning, oropharyngeal airway placement, endotracheal intubation and bag-valve-mask ventilation. Other than CPR, all emergency training of the 2012 student group was by means of apprenticeship in clinical rotations. Therefore, there was no evidence of the students’ competence or confidence with regard to their performance of emergency skills.

Objectives. To explore the effect of simulated skills training and assessments on medical students’ competence and confidence when using the skills required to manage clinical emergencies.

Method. A one-group pretest post-test quasi-experimental design was used, with a convenience sample (n=82) comprising final-year medical students from 3 of the 6 annual Family Medicine rotations. The participants’ competence (knowledge and selected emergency skills as per curriculum) and confidence were assessed before training. The intervention comprised training in relevant theory, demonstrations and supervised hands-on practice.

The post-training assessments were a repeat of the pretraining assessments.

Results. The improvement in participants’ confidence and competence levels when performing all the emergency skills on completion of the demonstrations and hands-on practice was highly significant (p≤0.001). Participants were unanimous in their opinion that pre-assessments had enhanced their learning experience.

Conclusions. The strategy of teaching/learning and assessment of emergency skills in simulation was highly effective in enhancing the competence and confidence of medical students when managing a clinical emergency. However, students appeared to be overconfident, which could be ascribed to ignorance, and possibly indicates that feedback during training should be improved.

Afr J Health Professions Educ 2015;7(2):155-157. DOI:10.7196/AJHPE.229

In 2010, a Skills Centre came into operation at the Medunsa campus of the University of Limpopo, which is situated 25 km north-west of Pretoria, South Africa. The medical core curriculum skills list was revised and skills that could be taught in simulated situations were listed for each of the 6 academic years. Since 2011, all 6th-year students have been required to manage 3 simulated clinical emergencies in small groups during the orientation period of the Family Medicine rotation. The skills incorporated in these simulations are cardiopulmonary resuscitation (CPR), airway suctioning, placement of an oropharyngeal airway (OPA), endotracheal intubation, bag-valve-mask (BVM) ventilation and defibrillation.

As the 2012 final-year students had not had exposure to the simulated emergency skills training currently scheduled for 4th-year students, their emergency skills training comprised apprenticeship in real-life clinical situations. Their formal emergency training was limited to CPR in their 4th year and endotracheal intubation and BVM ventilation in their 5th year of study. There was no evidence that these students had had opportunities to practise emergency skills during their practical rotations or of their competence and confidence when performing these skills.

Traditional bedside teaching, based on the apprenticeship model of education, cannot be relied on to provide adequate and comprehensive clinical skills training.[1] The healthcare systems (reduced hospital stay and a rapid advance in diagnosis and treatment technologies) have made this teaching method less effective, resulting in a sharp decline in standards of acquisition of clinical skills among medical students. The drawbacks of an apprenticeship methodology of skills acquisition (where learning is left

to chance and is unobserved by teachers) can, however, be overcome by structured and observed training in skills centres.[2] Growing evidence validating medical simulation as an educational tool has promoted its use beyond the instruction of physicians-in-training,[3] and skills centres have become an established part of training for healthcare professionals. Clinical skills centres provide students with the opportunity to practise clinical techniques on manikins and simulators in a safe environment, without affecting the quality of patient care. This has changed the centuries-old approach to learning medical procedures by first practising on a patient, to one where competency is first demonstrated on a simulator.

Simulation training, especially in emergency skills, is designed in such a way that healthcare providers can learn from practising in a situation that they are likely to encounter. It ensures that patients are not put at unnecessary risk by exposure to novice or out-of-practice caregivers,[4] and is also conducive to the conducting of objective assessments.

There is considerable debate on how accurately students assess their own competence. Several studies have shown that medical students’ self-perceived competence correlates poorly with objectively assessed competence.[5] Apart from inadequate self-assessment skills, biased selfevaluation in applied settings can also be ascribed to the overconfidence phenomenon. ‘We don’t know what we know, but we are confident we do … Not only are we wrong, but we are confident that we are right!’[6] A more serious problem that has been identified is that individuals at the lowest levels of mastery lack the metacognitive understanding of what actually constitutes mastery, leading them to greatly overestimate their own skills.[6]

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Research Competence and confidence are terms used for expressing beliefs about one’s ability to perform an activity. Confidence refers to self-assurance arising from an appreciation of one’s own abilities,[7] while in this study competence refers to the ability to perform a clinical skill successfully or efficiently. Competence can, however, be thwarted by a lack of confidence; however, misguided overconfidence in professional capabilities may have serious professional and malpractice consequences.[8] Clinical expe­ rience and the level of confidence have no predictive value in performance assessments when using standardised simulated scenarios. As self-confidence is not a reliable indicator of skills competence, it is important to measure both confidence and competence.[9] Final-year medical students have a sound theoretical knowledge of emergency procedures,[10] but how confident and competent are they in performing these procedures?

Objective

The objective of this study was to explore the effect of simulated skills training and assessments on final-year medical students’ competence and confidence in performing skills required to manage clinical emergencies.

Method

The study was conducted at the Skills Centre at Medunsa. The population of MB ChB VI students (N=176) was divided into 6 groups that rotated, as per curriculum, through 6 blocks of various disciplines during the year. A convenience sample (n=82) was used, comprising all the consenting students from 3 of these groups during their Family Medicine rotation. Ethical clearance was granted by the Medunsa Research and Ethics Committee and informed consent was obtained from participants.

A one-group pretest post-test quasi-experi­ mental design was used to determine the effect of skills training and assessment on students’ competence and confidence in performing emergency procedures. Pretraining assessments of participants’ competence (knowledge and selected emergency skills as per curriculum) and confidence were administered. The intervention comprised 3 training and practice sessions of 30 minutes each: (i) adult CPR and defibrillation; (ii) adult endotracheal intubation; and (iii) resuscitation of a paediatric patient (CPR, airway suctioning, placement of an OPA, and BVM ventilation). Three groups, each comprising 9 - 10 students, rotated through the 3 stations, each manned by 2 lecturers

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who supervised the students and, by implication, provided them with feedback.

The post-training assessments were a repeat of the pretraining assessments. Pre- and posttraining assessments were conducted on the same day to minimise the threat of maturation and history. To prevent social desirability bias the questionnaires were administered by the researcher, and responses to questionnaires were not accessible to the lecturers.

The pre- and post-training questionnaires comprised a 4-point Likert scale for self-report of confidence levels in performing 6 skills: CPR, clearing the airway by suctioning, placement of an OPA, endotracheal intubation, BVM ventilation and defibrillation. A statement on the effect of skills assessment prior to the teaching session was added to the post-training questionnaire.

The multiple-choice questions (MCQ) test, used before and after the training, comprised questions relevant to the range of skills. The test was compiled and verified by 4 lecturers involved in emergency care training. The Objective Structured Clinical Examination (OSCE) assessment tools were compiled and tested to assess objectively the skills performed

at each of the 3 OSCE stations. A pilot study with 43 students in the first Family Medicine rotation of 2012 was conducted to determine the viability of the instruments and timing of the activities. These results were not included in the study.

Results

The results of the MCQ test, questionnaires and OSCE were captured on an Excel spreadsheet.

The test and OSCE results before and after the teaching sessions were compared using Fisher’s exact test. All statistical tests were two-sided and p-values ≤0.01 were considered significant.

The mean scores of the pre- and post-training tests and OSCE assessments, the differences (improvement) and significance thereof are shown in Table 1.

The responses to the 4 categories of the Likert scale were summarised by frequency counts and percentages. The pre- and posttraining percentages of ‘competent’ outcomes (a combination of responses in category 1 (very confident) and category 2 (confident)) were compared using Fisher’s exact test. The mean scores of the pre- and post-training confidence

Table 1. Differences in the mean scores of pre- and post-training assessments (n=82) Mean score Mean score pretraining, % post-training, % Difference, %

Significance, p-value

MCQ test

42

64

21

0.0001

OSCE station 1 Paediatric resuscitation

23

74

51

0.0001

OSCE station 2 CPR and defibrillation

19

81

62

0.0001

OSCE station 3 Endotracheal intubation 16

52

37

0.0001

Assessments

Training

Table 2. Differences in pre- and post-training confidence levels in performing emergency skills (n=82) Skill

Confidence pretraining, %

Confidence post-training, %

Difference, %

Significance, p-value

Airway suctioning

66

100

34

<0.001

Placement of OPA

33

99

66

<0.001

BVM ventilation

81

100

19

<0.001

Endotracheal intubation

30

94

64

<0.001

CPR

87

100

13

<0.001

Defibrillation

33

96

64

<0.001

Table 3. Value of pretraining assessment (n=82) Value of OSCE

Strongly disagree, %

Disagree, %

Agree, %

Strongly agree, %

Created awareness

0

0

9

91

Enhanced learning

0

0

12

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Research levels, the differences (improvement) and significance thereof are given in Table 2.

Participants were unanimous (combination of category 1 (strongly agree) and category 2 (agree)) in their opinion that the pretraining OSCE had made them aware of their learning needs and the OSCE experience had enhanced their learning during the teaching session (Table 3).

Discussion

The lowest mean OSCE score was for endotracheal intubation (16% pretraining and 52% post-training). The medical students seem to find this emergency skill the most problematic. The literature shows that medical graduates feel inadequately prepared for performing an endotracheal intubation and it is recommended that more emphasis be placed on training medical students in this skill.[11] The improvement of participants’ competence in performing emergency skills in the post-training OSCE was highly significant (p<0.001). This improvement corresponds to the findings in a study on residents’ improved competence in critical resuscitation procedures following an intensive simulation-based training programme.[12] The literature reports low confidence levels and poor self-assessment of proficiency with regard to procedural skills among medical students entering clinical rotations. Their confidence improved significantly after a course in procedural skills.[13] Our results likewise indicate a highly signi­ ficant increase in confidence levels when performing each of the skills.

Students reported that the pretraining assessment (OSCE) improved their learning. This was similar to a report indicating that students who were evaluated prior to their training performed better in the post-training eva­ luation than a control group who had not been evaluated before training.[14] A limitation of this study was that, although the students seemed alarmingly overconfident, the data were unsuitable to statistically determine the correlation between competence (scores in percentages) and confidence (4 categories). An additional limitation was that individual feedback, as implied during supervised hands-on sessions, was not monitored. The absence of a correlation between confidence and grades could be the result of a lack of appropriate and clear feedback.[4] Students’ inflation of their abilities might be caused by ignorance rather than arrogance;[15] such exaggerated judgements might be the result of an absence of feedback or failure to incorporate feedback into self-perception.[5] Students tended to overestimate their own abilities. High-quality feedback[15] could act as an antidote to such inaccurate self-assessment.

Conclusion

The strategy of teaching/learning and assessment of emergency skills in simulation proved highly effective in enhancing the competence and

confidence of medical students in their management of a simulated clinical emergency. The improvement of students’ performance and confidence levels on completion of demonstrations and hands-on practice was highly significant (p<0.001).

The students appeared to be overconfident before engaging in this teaching/learning strategy. Their confidence levels escalated significantly on completion of the simulation, but were unfounded when compared with the proficiency scores. This confirms a finding previously reported in the literature that self-confidence is not a reliable indicator of skills competence.[10]

Recommendations

As students’ confidence levels were higher than their actual competency levels in the performance of emergency skills, it is recommended that training in the latter be expanded to include high-quality individual feedback. The effect of such individual feedback and its role in enhancing self-perception should be further researched.

Acknowledgements. I would like to acknowledge the help and contributions of staff from the Skills Centre (H Havenga, M Theron, Y Uys, B Randa, K Kgasi, T Zana and T van Dyk), the Department of Family Medicine (Drs K Hlabyago, H Mabuza, S Nyalunga, C Barua, I Govender and J Ndimande) and the students who participated in this study.

References 1. Remmen R, Derese A, Scherpbier A, et al. Can medical schools rely on clerkships to train students in basic clinical skills? Med Educ 1999;33(8):600-605. [http://dx.doi.org/10.1046/j.1365-2923.1999.00467.x] 2. Ahmed AM. Role of clinical skills centres in maintaining and promoting clinical teaching. Sudan J Public Health 2008;3(2):97.

3. Meguerdichian DA, Heiner JD, Younggren BN. Emergency medicine simulation: A resident’s perspective. Ann Emerg Med 2012;60(1):121. [http://dx.doi.org/10.1016/j.annemergmed.2011.08.011] 4. Brookes L. Developing simulation training for medical emergencies. Medscape interview, Paul Preston. http:// www.medscape.com/index/list_6121_1 (accessed 15 November 2012).

5. Lai NM, Teng Cl. Self-perceived competence correlates poorly with objectively measured competence in evidence based medicine among medical students. BMC Med Educ 2011;11(1):25. [http://dx.doi.org/10.1186/1472-692011-25] 6. Heath L, DeHoek A, Locatelli SH. Indirect measures in evaluation: On not knowing what we don’t know. Practical Assessment, Research and Evaluation 2012;17(6). http://pareonline.net/pdf/v17n6.pdf (accessed 15 November 2012).

7. Oxford dictionaries. http://oxforddictionaries.com/definition/english/confidence (accessed 20 March 2013).

8. Elzubeir MA, Rizk DEE. Assessing confidence and competence of senior medical students in an obstetrics and gynaecology clerkship using an OSCE. Educ Health 2001;14(3):373-382.

9. Hansen M, Oosthuizen G, Windsor J, et al. Enhancement of medical interns’ levels of clinical skills competence and self-confidence levels via video iPods: Pilot randomized controlled trial. J Med Internet Res 2011;13(1):e29. [http://dx.doi.org/10.2196/jmir.1596] 10. Remes V, Sinisaari I, Harjula A, Helenius I. Emergency procedure skills of graduating medical doctors. Med Teach 2003;25(2):149-154. [http://dx.doi.org/10.1080/014215903100092535] 11. Ochsmann EB, Zier U, Drexler H, Schmid K. Well prepared for work? Junior doctors’ self-assessment after medical education. BMC Med Educ 2011;24(11):99. [http://dx.doi.org/10.1186/1472-6920-11-99] 12. Langhan TS, Rigby IJ, Walker IW, Howes D, Donnon T, Lord JA. Simulation-based training in critical resuscitation procedures improves residents’ competence. CJEM 2009;11(6):535-539.

13. Stewart RA, Hauge LS, Stewart RD, Rosen RL, Charnot-Katsikas A, Prinz RA. A CRASH course in procedural skills improves medical students’ self-assessment of proficiency, confidence, and anxiety. Am J Surg 2007;193(6):771-773. [http://dx.doi.org/10.1016/j.amjsurg.2007.01.019] 14. Li Q, Ma EL, Liu J, Fang LQ, Xia T. Pre-training evaluation and feedback improve medical students’ skills in basic life support. Med Teach 2011;33(10):e549-e555. [http://dx.doi.org/10.3109/0142159X.2011.600360] 15. DeAngelis T. Why we overestimate our competence? American Psychological Association 2003;34(2). http:// www.apa.org/monitor/feb03/overestimate.aspx (accessed 13 November 2012).

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Research Student compliance with indications for intravenous cannulation during clinical learning C Vincent-Lambert,1 ND AET, NHD PSE, NHD FST, BTech EMC, MTech ED, PhD, HPE; B van Nugteren,2 ND EMC, BTech EMC 1

Department of Emergency Medical Care and Podiatry, Faculty of Health Sciences, University of Johannesburg, Doornfontein Campus, South Africa

2

Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Doornfontein Campus, South Africa

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

Background. Intravenous (IV) cannulation is a commonly performed procedure that is taught to a number of health science students. As with most invasive medical interventions, there is a possibility of unintended adverse effects. Therefore, IV cannulation should only be performed for a clearly established need.

Objective. To assess the extent to which emergency medical care students, during the course of their clinical learning, establish IV access in patients without a clearly documented indication.

Methods. A retrospective analysis of historical data from a clinical learning database was done to investigate whether patients seen by students over a 2-year period received IV cannulation in line with indications taught to students.

Results. Of the 5 893 cases reviewed, 1 862 (32%) were cannulated intravenously. Of these, 426 (23%) did not have a clearly documented indication that had been taught for the procedure. Therefore, these patients may potentially have been ‘overtreated’.

Conclusion. This study demonstrates that a high number of IV lines were established by students, with no clearly documented indication. This potential overtreatment may in part be attributed to pressures placed on students to achieve the minimum prescribed number of skills. Such practices remain common in medical education and may be detrimental to the patient. Medical educators need to ensure that students value the patient rather than the procedure. Further research needs to be conducted to investigate and identify other possible reasons for overtreatment of patients by medical students.

Afr J Health Professions Educ 2015;7(2):158-160. DOI:10.7196/AJHPE.273

One of the guiding principles of the teaching and performance of a medical intervention is to ‘firstly do no harm’. Gaining access to a patient’s circulatory system for the purpose of administering fluid and/or medications is commonly achieved through a procedure that involves piercing of the skin with a needle and inserting a cannula into a vein. While intravenous (IV) cannulation is a relatively common procedure routinely performed by a number of healthcare professionals, it has the potential to create unintended adverse effects. Subjecting patients to medical procedures in the absence of a clearly established need may be considered an unethical form of ‘overtreatment’. Conversely, failing to perform an intervention when it is clearly indicated is equally undesirable. Therefore, it is important for medical professionals and educators to ensure that there is a real need or an indication for IV cannulation before students perform the procedure.

The University of Johannesburg (UJ) is one of four higher education institutions in South Africa (SA) that currently offers a 4-year professional Bachelor degree in emergency medical care. IV cannulation is a clinical procedure that is taught in the second year of study. The didactic approach followed at UJ is to firstly teach and assess theoretical knowledge and understanding of the procedure with regard to the technique, indications, risks and benefits. The procedure is then demonstrated, practised and assessed in a simulated environment, making use of an IV trainer (medium-fidelity manikin). Thereafter, students are required to demonstrate performance of the procedure a set number of times on real patients. While this creates a desire in students to perform IV cannulation when the opportunity presents itself, as mentioned above, it is essential to seek clear indications to prevent unnecessary exposure of patients to potential adverse effects. The Department of Emergency Medical Care at UJ currently teaches four indications for IV cannulation in the

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prehospital setting, which are well supported in the literature. These include: (i) administration of IV fluid in an effort to reverse hypovolaemic and associated dehydrated states; (ii) administration of IV medications; (iii) securing IV access in the case of acutely ill, high-acuity ‘priority 1’ or ‘code red’ patients; and (iv) obtaining blood samples/specimens for further laboratory testing.

We aimed to assess the extent to which emergency medical care students may have been accessing patients intravenously during the course of their clinical learning, without a clear indication.

Method

A retrospective quantitative design was used comprising 5 893 cases from an existing database, Emergency Medical Database and Analysis System (EMDATA), which contains prehospital patient care records relating to students’ clinical learning, facilitated by the Department of Emergency Medical Care at UJ. Data from two consecutive academic years were extracted using Structured Query Language (SQL) statements and analysed to establish the number and percentage of the following patients seen by students over that period: • Those who received IV cannulation.

• Those who received IV cannulation and IV medication, but <500 mL of fluid.

• Those who received IV cannulation and >500 mL of fluid, but no IV medication.

• Those who received IV cannulation, >500 mL of fluid and IV medication.

• Those who were cannulated, acutely ill, high-acuity priority 1 patients, but who did not receive >500 mL of fluid or IV medication.

• Those who received IV cannulation, but were not acutely ill, high-acuity priority 1 patients, and did not receive IV medication or >500 mL of

Research fluid. This would constitute the cohort for whom there was no clearly documented taught indication supporting performance of the procedure.

Consequently, based on the data extracted from the database, this cohort of patients may have potentially been unnecessarily cannulated or ‘overtreated’.

Results

Table 1 summarises the cases per category.

Table 1. Cases per category Category

n (%)

Number cannulated intravenously

1 862/5 893 (32)

Received IV medication, but not fluid resuscitation*

431/1 862 (23)

Received fluid resuscitation,* but no IV medication

590/1 862 (32)

Received fluid resuscitation and IV medication

289/1 862 (16)

High-acuity (P1), but received no IV medication or fluid resuscitation*

126/1 862 (7)

Received no IV medication or fluid resuscitation and not high-acuity (P1)

426/1 862 (23)

IV = intravenous; P1 = priority 1. *Fluid resuscitation was defined as the administration of >500 mL fluid.

Discussion

Research in the SA prehospital emergency care education environment is in its infancy. Consequently, there is currently limited published literature describing the practices of local emergency medical care students. In an attempt to compare the abovementioned findings with the existing literature, we performed a literature search in the Medline database using medical subject headings (MeSHs) and textwords: ‘IV cannulation’ [MeSH], ‘prehospital’ [MeSH] and ‘emergency medi­ cal services’ [MeSH]. Articles published over the past 15 years were prioritised.

These searches highlighted that there was limited international literature on emergency medical care students and the performance of IV cannulation.

Patients who were cannulated intravenously

The percentage of patients (32%) in this study who received IV cannulation was found to be lower than that in international studies. Gausche et al.[1] found that 84% of the patients in their study were cannulated intravenously.

Two other studies found that peripheral IV cannulation had been performed in 57% and 58% of patients, respectively.[2,3] The lower percentage of patients who received IV cannulation in relation to international figures may be because, in SA, ambulances transport many low-acuity ‘stable’ ambulatory patients who do not require any form of prehospital medical intervention, but merely need transport to hospital.[4] Another reason may be that students work with ambulance crews whose scope of practice does not include IV cannulation. As students may only practise within the scope of the registered supervisor, they would not have been able to perform this skill – even if it were indicated.

Patients who were cannulated intravenously, received IV medication, but <500 mL fluid There were 23% of patients in this category compared with 71% who received only IV medication in the Minville et al.[2] study. One reason may be that many of the ambulance crews in SA with whom the students

work qualified at the Intermediate Life Support level. SA Intermediate Life Support providers have few IV medications in their scope of practice, yet are still able to establish an IV line.

Patients who were cannulated intravenously, received >500 mL fluid, but no IV medication

Of the patients who were cannulated, 32% received fluid resuscitation.

This is higher than the percentage reported in similar international studies, where only 7% and 5% of patients received fluid resuscitation, respectively.[1,2] The difference may be attributed to the higher incidence of trauma (with associated blood loss) to which SA emergency services respond. SA has one of the highest motor vehicle accident rates in the world. Violence and injuries are the second leading cause of death and lost disability-adjusted life-years in SA. The overall injury death rate of 158/100 000 population is nearly twice the global average.[5] Another possible reason is that local Basic and/ or Intermediate Life Support providers spend longer in the prehospital environment than their international counterparts.[6] Additional time spent treating and transporting patients allows for more fluid to be administered.

Patients who received >500 mL fluid together with IV medication

A total of 289 (16%) of the study patients received both IV medication and >500 mL of fluid. This could not be compared with international studies, as those reviewed did not identify these patients as a separate group.

Acutely ill, high-acuity priority 1 patients cannulated intravenously, but who did not receive >500 mL fluid or IV medication

As mentioned above, one of the taught indications for establishing IV access is obtaining IV access in the acutely ill, high-acuity priority 1 patient so that, should rapid deterioration occur during transit, the IV line is already in place. One hundred and twenty-six (7%) of the patients who received IV cannulation were categorised as high-acuity priority 1, but did not receive IV medication or >500 mL of fluid. This percentage is much lower than the 24% described in the Minville et al.[2] study. The reasons for this difference are not clear; it could be related to a failure by ambulance personnel and students to properly assess the patient and correctly predict deterioration.

Patients who were cannulated intravenously, but not cate­ gorised as high-acuity priority 1, received no IV medication and not >500 mL fluid Four hundred and twenty-eight (23%) of the patients did not have a clearly documented indication for IV cannulation, suggesting that they may have been potentially overtreated. This finding is similar to the 22% and 29% of IV lines that remained unused in the studies by Allen et al.[7] and Pace et al.,[3] respectively. However, the percentage is considerably lower than the 56% unused IV lines in the Gausche et al.[1] study.

As mentioned above, there is a paucity of literature describing the clinical education and training practice of emergency medical care students. Despite a number of searches, no studies could be found describing overtreatment of patients by such students. The reasons for overtreatment may include over-eagerness of the student and a desire to practise and master newly found clinical skills.

Barsuk et al.,[8] in dealing with medical education and learning, highlight the potential of simulation-based learning to assist in achieving minimum

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Research standards and mastery of clinical skills prior to interactions with real patients. Jantz and McGaghie[9] rightfully note that while many medical education programmes demand the performance of a set number of skills and procedures, the numbers are not scientifically validated. Nonetheless, the setting of minimum numbers naturally creates pressure on student and educator alike. Observations and feedback from students and educators in our emergency medical care environment are that there is indeed pressure to perform skills and interventions for the purposes of teaching, learning and assessment.

This study showed that of the 5 893 patients seen by students during the 2-year period, 1 862 (32%) received IV cannulation and, of these, 426 (23%) did not have a clearly documented taught indication for the procedure. This evidence suggests that these patients may potentially have been overtreated.

Subjecting patients to medical procedures in the absence of an evidencebased need may be considered an unethical form of overtreatment.

Conversely, failing to perform an intervention when it is clearly indicated is equally undesirable. Therefore, it is incumbent upon medical professionals and educators to ensure a real need or an indication for a procedure such as IV cannulation before performing the procedure. It is also acknowledged that emergency medical care students work under direct supervision. The power-authority relationship between them and their clinical mentors may limit their autonomy to make clinical decisions. Such findings are interesting and applicable to emergency medical care students and educators.

Medical educators should consider recent evidence and research in the area of simulation-based learning, as this appears to be an under-used didactic approach, which, if properly implemented, may reduce current overreliance on patient contact.

Conclusion

Of all the patients cannulated intravenously, few had medications admin­ istered via the established IV line. A higher number of patients received >500 mL of fluid than in similar international studies. In a number of patients an IV line had been established, yet they did not receive medications or clinically significant volumes of fluid, and were not documented as acutely ill, high-acuity priority 1. In such cases the indication to perform this procedure was unclear, and therefore these patients may have been overtreated. While IV cannulation remains a relatively common procedure routinely performed by a number of healthcare professionals, it has the

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potential to create unintended adverse effects. This study demonstrates that students established a significant number of IV lines – without a clearly documented indication. This potential overtreatment may in part be attributed to pressure placed on students to achieve a prescribed minimum number of skills. The value of quantitative approaches to determine clinical competence based purely on the performance of a skill or procedure a set number of times may be questioned, because many of the targets are not scientifically validated. Despite this, such practices remain common in medical education and may be detrimental to the patient. Medical educators need to ensure that their students value the patient rather than the procedure. Further research needs to be conducted to investigate and identify other possible reasons for overtreatment of patients by medical students.

Ethical considerations. Ethical clearance for the study was granted by the UJ’s Faculty of Health Sciences Academic Ethics Committee.

Protection of the patient’s rights to privacy. The researchers (CVL and BVN) signed a confidentiality agreement, stating that the information they had access to remained confidential. In light of the research design it was not necessary to identify individual students, patients, supervising practitioners, emergency medical service providers or receiving medical facilities. The researchers only extracted data from the database on the premises of UJ. The files remained password protected and were deleted after data extraction was complete.

References 1. Gausche M, Tadeo RE, Zane MC, Lewis RJ. Out-of-hospital intravenous access: Unnecessary procedures and excessive cost. Acad Emerg Med 1998;5:878-882.

2. Minville V, Pianezza A, Asehnoune K, Cabardis S, Smail N. Pre-hospital IV line placement assessment in the French emergency system: A prospective study. Eur J Anaesthesiol 2006;23:594-597.

3. Pace SA, Fuller FP, Dahlgren TJ. Paramedic decisions with placement of out-of-hospital intravenous lines. Am J Emerg Med 1999;17:544-547.

4. Geldenhuys N. The use of ambulances to transport patients to the Emergency Department of a public hospital in Johannesburg [Research Report]. Johannesburg: University of Johannesburg, 2011.

5. Seedat M, van Niekerk A, Jewkes R, Suffla S, Ratele K. Violence and injuries in South Africa: Prioritising an agenda for prevention. Lancet 2009;374:1011-1022. [http://dx.doi.org/10.1016/S0140-6736(09)60948-X] 6. van Hoving DJ, Smith WJ, Wallis LA. Comparison of mean on-scene times: Road versus air transportation of critically ill patients in the Western Cape of South Africa. Emerg Med J 2008;25:136-139. [http://dx.doi. org/10.1136/emj.2007.051540] 7. Allen B, Reisdorff EJ, D’Agostino J, Brown B, Shah CP, Thakur RK. Prehospital IV access: What is the impact?

Prehosp Emerg Care 1997;3:191-195.

8. Barsuk JH, Cohen ER, Vozenilek JA, O’Connor LM, McGaghie WC, Wayne DB. Simulation-based education with mastery learning improves paracentesis skills. J Grad Med Educ 2012;1:23-27. [http://dx.doi.org/10.4300/ JGME-D-11-00161.1] 9. Jantz MA, McGaghie WC. It’s time for a STAT assessment of bronchoscopy skills. Am J Respir Crit Care Med 2012;8:703-705. [http://dx.doi.org/10.1164/rccm.201208-1398ED]

Research Implementing and managing community-based education and service learning in undergraduate health sciences programmes: Students’ perspectives S B Kruger,1 PhD; M M Nel,1 PhD; G J van Zyl,2 MB ChB, MMed, PhD 1

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

2

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

Corresponding author: S B Kruger (krugersb@ufs.ac.za)

Background. A current challenge in the training of healthcare professionals is to produce socially responsive graduates who are prepared for work in community settings. Community-based education (CBE) and service learning (SL) are teaching approaches used in the Faculty of Health Sciences at the University of the Free State (UFS), Bloemfontein, South Africa to address these challenges. Students have different views with regard to CBE and SL, and by surveying these perceptions information can be gained on how to better integrate CBE and SL into learning programmes.

Objective. To investigate students’ perceptions of CBE and SL in a health sciences faculty.

Methods. Nominal group discussion was conducted to identify topics to explore students’ perceptions of CBE and SL. A questionnaire was administered to all undergraduate health sciences students at UFS to survey their perceptions of CBE and SL. Results. Twenty different themes were identified that had a positive or negative impact on the students’ perceptions of CBE and SL. Positive aspects included personal growth, exposure to a diversity of patients, gaining practical experience and enhancement of inter- and intrapersonal skills.

However, the students perceived the following as negative or inadequate: the organisation of CBE and SL; availability of resources; attitude of healthcare professionals; and prior orientation.

Conclusion. CBE and SL need to be carefully implemented and managed to enhance the learning experience for students and produce socially responsive healthcare professionals who are equipped to address the healthcare challenges in their communities.

Afr J Health Professions Educ 2015;7(2):161-164. DOI:10.7196/AJHPE.333

Globally, more than a billion people never consult a healthcare worker in their lives. Inequitable and ineffective healthcare systems are weakened by a scarcity and maldistribution of the healthcare workforce.[1] Together with other stakeholders, health professional schools can play a key role in reducing inequality and improving health equity. The Global Independent Commission on Education of Health Professionals for the 21st Century (2010) calls for transforming institutional and educational approaches to better meet changing health systems needs.[2] Furthermore, in late 2010, the Global Consensus for Social Accountability of Medical Schools (GCSA) urged schools to improve their response to current and future health-related needs and challenges in society and reorientate their activities accordingly.[3] From the above it follows that it is necessary for health professional schools to engage with the community as an essential strategy to achieve a diverse healthforce, increasing access to healthcare and eliminating health disparities.

In South Africa (SA), as in the rest of the world, community engagement plays an important part in higher education. Reorientation of health professions education to an inclusive primary healthcare approach was called for in the White Paper on the Transformation of the Healthcare System in SA.[4] Some[5,6] argue that the educational programme for health­care professionals should deliver graduates who are prepared for work in community settings, resulting from the move from fixed institutions, such as hospitals, to various settings in the community. Community-based education (CBE) and service learning (SL) as a means of achieving greater social responsibility have become more prominent in health professions education worldwide.

CBE in a medical context can be defined as learning activities that take place within communities and take into consideration the main health problems of the country, but do not directly engage the community in the design, conduct and/or evaluation of these activities.[7,8] SL has been defined as ‘an educational approach involving curriculum-based, credit-bearing learning experiences in which students (a) participate in contextualised, well-structured and organised service activities aimed at addressing identified service needs in a community, and (b) reflect on the service experiences in order to gain a deeper understanding of the linkage between curriculum content and community dynamics, as well as achieve personal growth and a sense of social responsibility. It requires a collaborative partnership context that enhances mutual, reciprocal teaching and learning among all members of the partnership.’[9] The Faculty of Health Sciences at the University of the Free State (UFS), Bloemfontein, SA recognises the tremendous potential of CBE and SL to enhance health professions education, as both allow students to apply the information they learn in the classroom to real-world settings and provide an important avenue for self-reflection. CBE and SL contributed to the restructuring of clinical education in the Faculty, and various modules using CBE and SL are offered throughout the different study years across the various programmes. In our Faculty, CBE and SL vary, e.g. in terms of duration and number of outreaches.

Students’ ability to learn is to a great extent affected by their perception of the specific learning environment. Perception in this study refers to the way students view, understand and interpret CBE and SL. If students have a

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Research negative perception of the learning environment, they will have a negative attitude towards the learning that is expected to take place, which could result in less effort put into the task at hand and ultimately less learning.

Positive attitudes and perceptions may be encouraged by creating a better learning climate, ensuring the quality and quantity of the resources and gaining individual acceptance of the students.[10] It is important to understand students’ perceptions with regard to CBE and SL and take these into consideration in the design and implementation to enhance the students’ experiences, which will in turn enhance the success thereof and result in graduates who are more socially responsive, able and willing to work in community settings.

included students instructed in either Afrikaans or English, as well as male and female students.

Methods

Data analysis

A combination of methods was used to generate data; these findings were interpreted to form the basis for the recommendations on the improvement of CBE and SL. During Phase I of the mixed-methods research design, data were collected by means of a nominal group technique. Nominal group discussions were held with the class leaders to identify possible themes/ topics to describe the perceptions of health sciences students with regard to CBE and SL. These themes and topics were used to design a questionnaire, which formed Phase II of the research.[11] The questionnaire survey used a quantitative approach with elements of qualitative research. The aim of the survey was to obtain demographic information of the participants, explore the students’ perceptions regarding CBE and SL, and identify whether there are certain factors that influence students’ experiences of CBE and SL. The questionnaire contained both open-ended and closed questions, with various scaling methods, e.g. nominal measurements were used in the demography section, while a Likert scale was used to obtain measurements from the closed questions in the other sections.[11] Sufficient open space was provided after the open-ended questions so that respondents could write down their comments/responses.

Results

Study design

Study population

A questionnaire survey was administered to all students registered for undergraduate degree programmes in the Faculty of Health Sciences, UFS, who participated in CBE and/or SL during 2011. Of the 1 063 students registered, 792 (74.5%) completed the survey (Table 1). The population Table 1. Numbers of registered undergraduate students in the Faculty of Health Sciences, UFS, who completed the questionnaire survey (N=792) Year of study Academic programmes

I

II

III

IV

V

Total

MB ChB

128

0*

99

54

76

357

B Occupational Therapy

31

31

6

27

NA

95

BSc Physiotherapy

40

33

38

30

NA

141

BSc Dietetics

0*

0*

0*

18

NA

18

B Optometry

0*

0*

23

0*

NA

23

BSocSc (Nursing)

60

27

30

41

NA

158

259

91

196

170

76

792

Total

NA = not applicable, as these programmes are 4-year degree courses. * No CBE/SL in these study years.

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Data collection

Questionnaires were handed out to students directly after an academic contact session, following their completion of the CBE or SL section in their respective modules. Participation was voluntary and questionnaires were completed anonymously. Students had 20 minutes to complete the questionnaire, which gave them adequate time to consider their answers.

After completion of the questionnaires, the participants placed these in a box to ensure anonymity and confidentiality.

Quantitative data from the questionnaire surveys were analysed descriptively by the Department of Biostatistics, UFS, using frequencies and percentages for the categorical variables. The qualitative data were analysed by the researcher (SBK) by reading and reflection, identification of themes, establishment of patterns and connections, as well as coding. Following the analysis of the data, both the quantitative and qualitative data were categorised into different themes.

Ethical approval was obtained from the Ethics Committee at the Faculty of Health Sciences, UFS (ECUFS No. 77/2011).

Twenty different themes were identified and divided into aspects that had either a positive or a negative influence on the way students perceived CBE and/or SL. The themes are presented in Table 2, together with some of the verbatim quotes from the students to substantiate the theme.

Discussion

Based on the information obtained by means of the questionnaire survey, it was clear that the students regarded CBE and SL as valuable and enjoyed it. They agreed that by means of CBE and SL they had the opportunity to experience the ‘human aspect’ of patients, could put their knowledge into practice, and learn about the roles and values of the multidisciplinary teams. CBE and SL improved their sensitivity towards other cultures, self-confidence, interpersonal communication skills, problem-solving skills and other professional competencies.

However, a number of aspects that students perceived as negative were identified. Consequently, certain recommendations could be made with regard to the improvement of CBE and SL in the Faculty of Health Sciences, with a view to enhance the experiences of undergraduate health sciences students.

The researcher proposes that when implementing and managing CBE and SL in undergraduate health sciences programmes, certain steps should be included to enhance the students’ experiences thereof and meet the underlying principles for which CBE and SL are intended (Kruger SB. Community based education and service learning: Experiences of health sciences students at the University of the Free State. Unpublished Doctoral Thesis. Bloemfontein: University of the Free State, 2013). The steps proposed by SBK concur with those set out by the Higher Education Quality Committee (HEQC)[11] for the development of a curriculum model for service learning, with certain key steps in the development of a CBE programme.[12]

Planning CBE and SL

A number of important steps need to be taken when planning CBE and SL. The first step is to set clear module outcomes. It is crucial to ensure

Research

Table 2. Themes that influenced students’ perceptions of CBE and SL Positive

Verbatim quotes by students

Achievement of personal growth

‘It helped me to grow as a person which made me more competent in my personal life.’

‘Gained personal growth and development.’

Exposure to a variety of conditions/cases in their respective fields of study

‘Diversity in the patient profiles.’

‘It is challenging, there is a huge variety in patients.’

Enhancement of social responsiveness

‘There it feels like I am actually making a difference.’

‘It gives one a great sense of purpose.’

Gaining interpersonal skills

‘To enhance personal relations with my peers and other professionals.’

‘To be able to learn and experience with my fellow students.’

Exposure to different cultures

‘Working with different cultures.’

‘Give insight into other cultures.’

Application of theoretical knowledge

‘It is nice to experience everything in practical and not only to learn in theory.’

‘Challenging. Learn a lot more through experience.’

Expanding theoretical knowledge

‘It gave me a new perspective and challenged me to search for solutions to some problems.’

Gaining professional competencies

‘Took me out of my comfort zone and I learnt new competencies.’

‘Had to make decisions yourself and bear responsibility. I enjoyed it.’

Feeling valued in the community

‘To see how thankful the people are afterwards.’

‘It was nice to see how thankful the less fortunate was for the help they receive.’

Working in multidisciplinary teams

‘To see how the multidisciplinary team works and experiences the hospital environment.’

‘It helps me to learn more about other fields.’

Gradual introduction into clinical field

‘It gives one a viewpoint of how things in the future in your career can work from early on in your studies.’

Negative Poor organisation

‘To have set out schedules/time tables to minimize wastages.’

‘Place the students where there are learning opportunities other than being at a place yet you have nothing to do.’

‘Monitor students attendance regularly, it is bad that some students never attend sessions and lie and get away with that.’

Negative attitude of healthcare professionals

‘The staff at the community centers should be encouraged to be more willing to teach.’

‘Only staff that are willing to be involved with students should be involved.’

Feeling unproductive

‘Place the students where there are learning opportunities.’

‘Theory in class does not match the practical aspects.’

Exposure to traumatic situations

‘The necessary debriefing after traumatic experiences.’

‘It gets overwhelming in the final year and there is very little support for the students, it gets very depressing at times.’

Availability of resources

‘Improve hospital conditions.’

‘The clinics need proper equipment.’

Communication difficulties

‘Communication between the faculty and the skills providers at the community facilities needs to be improved.’

‘An effort to communicate better with students as to the state of affairs.’

‘Learn Sesotho.’

Transport problems

‘Transport must be available.’

‘Not all students have cars, organise transport.’

Insufficient orientation

‘Enough training beforehand should be conducted.’

‘Maybe prepare students in depth as to what is expected of them.’

Unstructured reflection

‘Reflections need to be more structured and done in private.’

that these outcomes address the healthcare needs of the community; clarify social, economic, cultural and political issues underlying the source of community needs; and enhance academic learning, personal growth and social responsibility of students. These outcomes should be clear, action orientated and measurable.

The second step is to assign tasks to the learning outcomes that are applicable to the students’ level of knowledge and skills, in line with the outcomes and achievable in the community.

Thirdly, teaching methods can then be assigned to the different tasks.

These teaching methods should be in the correct combination and level of students’ knowledge and skills to facilitate and support learning from communities and integration of experiential learning.

The fourth and fifth steps are to assign assessment criteria and academic credits to the activities.

The next steps may be done in any order or simultaneously. Appropriate community service placements should be selected, with healthcare needs

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Research that relate to the set module outcomes, and students should have the appropriate skills and knowledge to address these needs. Furthermore, community settings should provide students with exposure to a variety of pathologies, be able to accommodate the students and have the necessary resources.

Academic staff should plan the duration of CBE and SL activities and schedule them in the students’ academic rosters. Time frames should be reasonable to successfully complete the activities. Healthcare personnel from multiple professions and across disciplines have to be recruited and appointed. They should be knowledgeable, willing and able to supervise students and receive training with regard to their roles, responsibilities and module outcomes. Sufficient transport should be arranged and a professional counsellor or psychologist should be available to assist students with traumatic emotional experiences.

The final step that needs to be taken when planning CBE and SL is to orientate the students. Orientation should include the following elements: • Introduce the concepts of CBE and SL. • Emphasise the importance of CBE and SL. • Prepare students with regard to what to expect.

• Orientate students to module-specific content.

• Explain what is expected of students in terms of outcomes.

• Explain assessment criteria.

• Discuss student reflections and indicate the frequency, format and content.

• Inform students about support services, e.g. transport, psychologist.

• Divide students into groups (multicultural and different languages).

• Hand out schedules.

• Provide clear directions to community sites.

• Inform students about professional courtesy, ethics, rights and responsibilities.

• Discuss the different activities that students need to perform.

• Discuss possible challenges and problems that students may encounter and possible solutions.

Actions during CBE and SL

The following actions should be executed on a continuous basis throughout the duration of CBE and SL: students’ attendance should be strictly monitored at all times. Regular communication should take place between all stakeholders, including initial consultations with individuals at community settings and healthcare facilities at the beginning of CBE and SL to identify the broad healthcare needs of the community, negotiate CBE and SL activities and the aims and objectives of such activities, highlight the potential benefits for the community, and emphasise the importance of mutual respect and co-operation.

Other important actions are that academic staff should have regular meetings throughout the duration of CBE and SL at community settings and healthcare facilities with individuals, supervisors and students to ensure that everyone is working towards the same goal and objectives, confirm schedules for future CBE and SL, identify problems and challenges and discuss possible solutions. It should also be confirmed whether the necessary resources are available at the different sites where CBE and SL are planned.

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After CBE and SL

On completion of CBE and SL it is important to celebrate the success with all the relevant role players and show appreciation for their respective inputs in the success of the initiative.

Allow students to evaluate CBE and SL and receive their inputs and feelings with regard to the experience. Evaluate whether module outcomes have been met and students’ personal growth and social responsiveness have increased. These evaluations and recommendations may be used to adapt CBE and SL if necessary.

Conclusion

The current challenge of health professionals’ training is that programmes should produce graduates who are prepared and willing to work in community settings to improve the current health status of individuals and groups and the health systems performance of the country in which they live. CBE and SL are teaching approaches to address this challenge. If CBE and SL could be implemented and managed successfully and students perceived it as positive learning experiences, they would acquire an understanding of the current health needs and challenges facing communities, have the opportunity to apply their theoretical knowledge, and learn in an environment that resembles their future professional career environment. Moreover, they will be equipped with a number of professional competencies and skills, experience interprofessional and multidisciplinary teams working together and interact with different cultures, while their social responsiveness will be enhanced.

The description of the perceptions of undergraduate health sciences students concerning CBE and SL generated from this study may be generalised beyond its local application as it may be applicable to other situations and groups. Therefore, the researcher proposes expansion of the use of the survey instrument developed for the purpose of this study by other faculties at UFS and other faculties of health sciences, both locally and internationally, as a means of generating comprehensive information regarding students’ perceptions of CBE and SL in other settings, as well as encouraging future research in this regard.

References 1. The Training of Health Equity Network. THEnet’s Social Accountability Evaluation Framework Version 1.

Monograph I. 1st ed. New York: THEnet, 2011.

2. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. [http://dx.doi.org/10.1016/S01406736(10)61854-5] 3. Global Consensus for Social Accountability of Medical Schools: Position Statements Global Consensus for Social Accountability of Medical Schools, 2010. http://healthsocialaccountability.org/ (accessed 10 January 2013).

4. Department of Education. A Programme for the Transformation of Higher Education. Education White Paper 3.

Notice 1196. Pretoria: Government Printer, 1997.

5. Frank B, Adams MH, Edelstein J, Speakman E, Shelton M. Community-based nursing education of prelicensure students: Setting and supervision. Nurs Educ Perspect 2005;26(5):283-286.

6. Nokes K, Nickitas D, Keida R, Neville S. Does service-learning increase cultural competency, critical thinking and civic engagement? J Nurs Educ 2005;44(2):44-53.

7. Strasser R. Community engagement: A key to successful rural clinical education. Rural Remote Health 2010;10(3):1543.

8. Kristina TN, Majoor GD, van der Vleuten CP. Defining generic objectives for community-based education in undergraduate medical programmes. Med Educ 2004;38(5):510-521. [http://dx.doi.org/10.1046/j.1365-2929.2004.01819.x] 9. University of the Free State (UFS). Community service policy of the University of the Free State. 2006. http:// supportservices.ufs.ac.za/dl/userfiles/Documents/00000/357_eng.pdf (accessed 26 August 2015).

10. Marzano RJ. Dimension 1: Positive Attitudes and Perceptions About Learning. A Different Kind of Classroom: Teaching with Dimensions of Learning. Alexandria, VA: Association for Supervision and Curriculum Development, 1992. http://files.eric.ed.gov/fulltext/ED350086.pdf (accessed 26 August 2015).

11. Higher Education Quality Committee (HEQC). Service-Learning in the Curriculum: A Resource for Higher Education Institutions. Pretoria: Council on Higher Education, 2006.

12. Morgan S, Smedts A, Campbell N, Sager R, Lowe M, Strasser S. From the bush to the big smoke – development of a hybrid urban community based medical education program in the Northern Territory, Australia. Rural Remote Health 2009;9(3):1175.

Research Preclinical medical students’ performance in and reflections on integrating procedural and communication skills in a simulated patient consultation I Treadwell, DCur, HED Skills Centre, Sefako Makgatho Health Sciences University (formerly Medunsa Campus of the University of Limpopo), Pretoria, South Africa Corresponding author: I Treadwell (ina.treadwell@gmail.com)

Background. An effective patient-centred consultation requires the seamless integration of procedural (technical) and communication skills.

Research has shown that the two sets of skills should not be taught or assessed separately; yet, clinical communication education has become separated from other parts of medical education.

Objectives. To assess students’ performance of integrated procedural and clinical communication skills in a simulated consultation, and analyse and interpret their reflections on the value and challenges of these integrated assessments.

Methods. A mixed-method study was conducted to assess a convenience sample of 207 third-year medical students’ integration of procedural and consultation skills in a simulated patient consultation and explore their self-assessment and reflections on the value of the assessment.

Results. The average percentages scored for procedural and communication checklist items were compared. Facilitators and participants scored procedural skills significantly higher, indicating poor integration of communication skills. A thematic analysis of written reflections revealed that students learned by: (i) experiencing an authentic consultation; (ii) integrating their procedural and communication skills as well as their knowledge and skills; (iii) experiencing the assessment as learning; and (iv) becoming aware of the effects of emotion.

Conclusion. Although the majority of students were not able to integrate their skills in performing a simulated consultation, they nonetheless appreciated the value of the assessment as a learning experience.

Afr J Health Professions Educ 2015;7(2):165-169. DOI:10.7196/AJHPE.334

For various reasons training in clinical communication has become separated from other aspects of medical education and tends to be dealt with early in the curriculum.[1] Performing a clinical procedure involves two sets of skills – those related to conducting the procedure and those related to communicating with the patient. Although inextricable in practice, these sets of skills are usually taught separately, often by different departments in an institution.[2] Teachers of clinical communication, whether faculty or clinically based, may not share the learning goals for acquiring communication skills, which may lead to a disjointed learning experience for students.[1] As clinicians are expected to integrate technical with communication and other professional skills, these should not be taught separately. Nontechnical skills, although essential in carrying out a clinical procedure on a conscious patient, can be ignored in simulation-based teaching.[2] Other disadvantages of simulation include learning in isolation from the clinical context and assessment practices that traditionally focus only on the technical elements of clinical procedural skills.[3] In an effort to avoid these possible disadvantages of simulation, realistic clinical scenarios can be created by linking bench-top models with simulated patients (SPs).

Students can then perform procedures in a safe environment, where many of the contextual cues of clinical practice are recreated.[2] SPs are usually lay people who are trained to portray a patient with a specific condition. When trained to play a role during an examination in a consistent way – one which does not vary from student to student – they are referred to as standardised patients.

Seamless integration of the procedural and communication skills is a process that requires practice and reflection. Reflection, defined as aware­ ness or analysis of one’s own learning or thinking processes, is regarded as an essential skill in learning and metacognition.[4] Reflection on action stimulates the student to consciously re-evaluate the experience and decide what could be done differently the next time he/she is in the same situation.

Structured reflection after a clinical encounter, either oral or written, is therefore a useful strategy to enhance learning and reasoning.[1] At the University of Limpopo (Medunsa campus) in Ga-Rankuwa, 25 km north-west of Pretoria, South Africa, students are introduced at the beginning of their medical degree programme to procedural and clinical communication skills as separate skills. During the first 3 years, the focus is on history taking and communication skills; the focus widens to include consultation skills in their third year. Procedural skills include urine testing, venepuncture, intravenous infusions, basic clinical examination of adults, including vital signs and anthropometric measurements, palpation of a pregnant abdomen, normal delivery and repair of an episiotomy. Several disciplines, in collaboration with the Skills Centre, are responsible for the teaching and assessment of these skills. These preclinical students have limited experience of the clinical workplace and working with patients. The ultimate accomplishment would be the integration of their acquired skills in a patient-centred consultation in preparation for their years of clinical training and future role as doctors.

Assessing the students through a patient-centred consultation will provide an opportunity to explore their ability to integrate skills and

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Research allow lecturers to determine the influence of this assessment approach on their learning. The questions that arise are how well preclinical medical students integrate procedural and clinical communication skills, despite having acquired them separately during various academic blocks; and how these students learn by being assessed in a simulated consultation that requires integrated skills.

It is hoped that this research will provide sufficient evidence of the importance of using SPs in integrated Objective Structured Clinical Examinations (OSCEs) at Medunsa and will pave the way to the enhancement of the integration of procedural and communication skills throughout the medical curriculum.

Objectives

The aims of the study were: (i) to determine preclinical medical students’ ability to integrate procedural and communication skills in a simulated consultation; and (ii) to determine which aspects of the simulated consultation they valued as a learning experience.

The objectives were: • to assess students’ performance of integrated procedural and clinical communication skills in a simulated consultation • to analyse and interpret students’ reflections on the value and challenges of the integrated assessments.

Methods

A mixed-method study was conducted: a descriptive study to observe and assess students’ performance in the consultation OSCE and a qualitative inquiry to explore participants’ reflections on their learning through the integration of procedural and clinical communi­ cation skills in a simulated consultation. A qualitative inquiry was appropriate in studying process evaluation, as participants’ reflections are considered a key process.[5] The population included all students enrolled in the third year of medical studies at Medunsa in 2012 and who were assessed during the mandatory end-of-year OSCE. All students (N=250) signed an informed consent form, but the data of only 207 (83%) were used owing to incomplete assessment records.

Ethical clearance for conducting the study was obtained from the Medunsa Research and Ethics Committee.

This newly introduced OSCE was conducted during the only free time available in the students’

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timetable, and it allowed for only a 15-minute assessment per student. Four scenarios were developed by a panel, comprising the third-year students’ practice co-ordinator and 4 facilitators from the Skills Centre. The panel ensured that the scenarios for the consultations were structured in such a way that they were balanced with regard to difficulty and time allowed to perform the required skills. Each scenario comprised skills the participants had acquired during the first 3 years of study. These included the essential history data, vital signs and instructions on the focused physical examination, and 2 skills to be performed on a young, female standardised patient (Box 1).

An assessment checklist was compiled for each consultation by combining previously used instruments for the individual skills, including items covering the communication skills required in the scenario. Each item on the checklist was rated ‘competent’, ‘incompetent’ or ‘not done’.

Content validity of the assessment checklists was assured by 4 facilitators involved in teaching procedural and clinical communication skills, who validated the appropriateness of the items on the checklists.

All activities took place in the Skills Centre.

Prior to the OSCE, the participants were orientated regarding the expectations of a SP-centred consult­ ation, and the individual assessment checklist was made available online to ensure that learners were aware of the task requirements and major components of a given task. The advantages of students having access to assessment tools before practical examinations are supported in the litera­ ture.[6,7] Neal et al.[7] demonstrated that trainees provided with a checklist beforehand performed significantly better in their medical management and non-technical performance during a simulated episode. Participants had the opportunity for revision and supervised practice of the individual skills mastered in their first year of study.

On completion of each OSCE session, the participants assessed their performance using a checklist, similar to the one used by the assessor.

They also recorded their reflections in writing, guided by two questions: (i) Did the integration of communication and procedural skills on an SP help you to learn?; and (ii) What did you experience as valuable and challenging in the OSCE? Reflections were written individually and directly after assessments to ensure that students’ views were not influenced by discussions with fellow participants.

The quantitative data collected in the study were captured on Excel spread sheets. Data capturing was verified and validity checks were performed as part of the data-cleaning process. The average percentages of competent performances in procedural and clinical communication skills items were compared using the Fisher exact test.

All statistical tests were two-sided and p-values ≤0.001 were considered significant.

A systematic process was used to identify themes from the written reflections. The researcher and the third-year co-ordinator read and reflected upon the data independently.

They identified the themes and categories that emerged. Thus, they indexed and sorted the data using the constant comparative method.[8] The themes and categories that emerged were identified through iterative (thematic) analysis.

Consensus on the 4 main themes was reached through further perusal of the data. Quotations were used to illustrate some of the participants’ views in their own words, adding to the validity and reliability of the results.

Results

Participants’ performance of procedural and clinical communication skills The average scores allocated by the facilitators were compared with the average self-assessment scores of the participants. The facilitators and

Box 1. Example of an OSCE scenario and instructions Mrs … is a 27-year-old woman who is making her first visit to the antenatal clinic.

The clinic nurse has already: • obtained her history: LMP (2012/01/01), EDB (2012/10/01), gravida 2 and para 1 • checked her temperature (37°C), pulse (80 bpm) and weight (78 kg) • given her health education about lifestyle issues (importance of good nutrition and avoidance of tobacco, alcohol and drugs) Use this time to plan your consultation with Mrs … , which must include the following procedures: • abdominal palpation to determine the gestation and lie of the fetus • blood pressure measurement • urine test

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Research

Table 1. Facilitator and participant scores for procedural and communication skills (n=207) Procedural skills

Difference

Significance

%

SD

%

SD

%

p

Facilitators

71.3

17.1

50.8

21.9

20.5

<0.0001

Participants

68.8

19.6

54.3

23.1

14.6

<0.0001

Assessor

Communication skills

Table 2. Facilitator and participant scores for procedural skills of participants who repeated the OSCE (n=53) OSCE 1

OSCE 2

Difference

Significance

%

SD

%

SD

%

p

Facilitators

54.8

13.4

83.5

11.4

28.7

<0.0001

Participants

60.6

19.7

75.7

16.3

15.1

<0.0001

Assessor

Table 3. Facilitator and participant scores for communication skills of participants who repeated the OSCE (n=53) Difference

Significance

%

OSCE 1 SD

%

SD

%

p

Facilitators

32.7

14.7

61.9

21.8

29.2

<0.0001

Participants

39.3

16.2

62.2

20.1

22.9

<0.0001

Assessor

participants scored procedural skills significantly higher than communication skills (Table 1).

There was a highly significant improvement in both procedural skills (Table 2) and commu­ nication skills (Table 3) as scored by facilitators and participants in the second OSCE for the 53 participants who scored <60% in the first OSCE. As in the first OSCE, the communication skills were scored significantly lower than the procedural skills by facilitators (21% lower) and participants (13.5% lower).

Participants’ written reflections on the value and challenges of the integrated assessment Almost all participants (94%) reported that the integration of communication and procedural skills on an SP had helped them with their learning.

Themes identified in the analysis of participants’ reflections on what they regarded as valuable to their learning and challenging about the OSCE correlated with some recognised learning strategies (authentic learning, integrative learning, assessment as learning) and the impact of emotions on learning.

Authentic learning (materials and activities framed around ‘real life’ contexts) • Two recurring values emerging from parti­ cipants’ responses were that the learning was realistic and relevant:

OSCE 2

‘ Doing a consultation as required in practice is relevant and more realistic.’

‘A real consultation helps the learning process.’

‘It felt real ... communicating while doing

procedures.’

‘The OSCE gave us a chance to know what to expect and deal with it in real settings.’

• The use of SPs humanised the consultation and was the most important element in making the consultation realistic: ‘Having a “real” patient puts things into

perspective.’

‘Working with a real person makes the skill come alive.’

‘I learnt that there is much more to a patient than just the condition.’

‘I realised the importance of not just examining patients as if they were objects.’

‘One can see a facial expression if not comfort­ able when a procedure is done on him.’

• Various aspects of SP encounters challenged the participants: ‘It was a challenge to explain the concepts to the patient.’

‘Having to explain to the patient some words like vocal fremitus … .’

‘I did not make the patient feel at ease. He must have been traumatised.’

‘ Encounters with a patient [SP] is intimidating but helps exploring yourself and learning from your own mistakes.’

‘Communication was a challenge – I was

thinking about what the assessor wanted to hear and not considering the patient.’

• The participants commented on the value of the experience in preparing them for future interactions with patients: ‘It resembles more or less the situation you will be in in the future.’

‘It gave me the opportunity to practise what I would do in real life.’

‘Time was a challenge … [OSCE] valuable for time management.’

• The scenario provided a realistic simulation which outlined the step-by-step process of a consultation. Participants appreciated the value of the structure in helping them to conduct the consultation: ‘The preparation … helped me to do the skill in a systematic manner.’

‘Sometimes I had to wait and recall what is next, it is not in me yet.’

‘Remembering sequence and doing procedure accurately was a challenge.’

‘Being a doctor and deciding what to do next made me enjoy the OSCE.’ ‘It is motivating for me to look back at the stuff I have learned in first year and second year. I also learned some new stuff.

I now see that medicine is a life learning process.’

Integrative learning • Integration of knowledge and procedures: [The OSCE] ‘ … allowed us to integrate knowledge and skills we have acquired in the last 3 years.’

It [the OSCE] ‘ … integrates everything we have learnt but … doing what I have read was a challenge.’ ‘ The procedures seem easy when going

through them theoretically.’

‘When theory is put into practice … you

understand the procedure and become confident in performing it.’

‘Correlating the information to the procedure helps to understand the reason for doing certain procedures.’

‘Having to take the blood pressure and relate it with the history and talking to the patient helps thinking and integrating what I have learned.’

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Research • Integration of procedures and communication: This was the first occasion where participants were required to integrate both aspects of a consultation, providing them with insight into the challenges posed.

‘The OSCE made me aware of the importance of incorporation of skills and communication – I didn’t realise it was this important.’

‘Integration is a challenge … speaking and doing skills.’

‘Synchronising the whole procedure and getting good rapport with the patient.’

Assessment as learning • Participants reported feeling under pressure when preparing for the assessment and becoming aware of what they lacked: ‘The OSCE was a good idea but nerve wracking – it forced me to learn.

Students only learn well when pressure is put on them.’

‘OSCEs help me to practise and make learning a nice but challenging experience.’

‘Skills need a lot of practice – even if you think you know them. Practice makes perfect.’

‘Helps you to see your weak points and where you must improve.’

‘Showed me that I wasn’t prepared and I have to put in extra effort.’

‘I found out where I’m still lacking.’

‘It made me aware of the silly mistakes that can be done in the ward.’

‘I realised that skills need to be constantly done in order to perfect the skill.’

Impact of emotion on learning • Participants experienced stress and the desire to cope with the situation: ‘The OSCE stresses you up … it helps to get used to the situation.’

‘Great learning experience to work under pressure … learn to calm down.’

‘It gives you a feel of what it will be like and calm the nerves before you are in a situation where there is no one to assist you.’

‘Anxiety … I need to find a way to deal with it … try to stay composed.’

• Some participants viewed their anxiety/stress/nervousness as the reason for their failure to perform better: ‘I was so nervous I fumbled the whole thing.’

‘Nervous … forget to mention vital stuff.’

‘Being scared makes it harder.’

‘I was shaking and nearly pricked myself.’

• Others experienced positive emotions: ‘Gain confidence in interacting with your patients.’

‘It made me feel confident enough to face patients at hospital.’

‘It made it more real, somewhat more enjoyable.’

‘Being the doctor and deciding what to do next made me enjoy the OSCE.’ ‘I loved the adrenaline that working against time gives you.’

‘Communication is always fun but the challenge was trying not to mess up with skills.’

Discussion

The students, who were taught communication skills by different departments and separately from procedural skills in the Skills Centre, performed significantly worse in communication skills than in procedural skills when both were required in a consultation. Such an obvious divide in performance on two sets of skills could be the effect of a neglect of interpersonal skills in simulation-based teaching of procedural skills.[2] This

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is aggravated by assessment practices that focus only on the technical elements of clinical procedural skills,[3] which is currently the case at Medunsa.

Almost all the students in the study experienced the OSCE as a valuable learning experience. This also became apparent in the second OSCE, where the scores of the students who were repeating the OSCE increased significantly in both the procedural and communication items. Similar to findings by Kneebone et al.,[2] students seemed to have learned through reflecting on their performances, and by using rating scales and checklists identical to those of the facilitators. The improved performance may also have been influenced by students’ awareness of their shortcomings, gained through reflection on their experience.

Students perceived the value of the OSCE as being its similarity to an encounter with a real patient. Learning is best achieved in an authentic learning environment in circumstances that resemble the real-life application of knowledge.[9] Nestel et al.[10] emphasise that scenarios should provide realistic simulations and prove feasible in terms of time, facilities and resources. Scenario-based assessments should reflect real-world issues of patient-centred care.

The authentic experience in this study was created primarily through the use of SPs, who humanised the consultation and posed the challenges of dealing with human beings. Walker et al.[11] observed that SPs provide students with an experience that is consistent with reality, increasing the validity and depth of the learning experience.

Authenticity with regard to preparation for future patient encounters was also valued. Providing a concrete learning experience had a positive impact on students’ learning processes. Experiential learning, or learning by doing, emphasises the role of experience as central to the learning process. It engages students and challenges their ideas and beliefs, encouraging them to create new knowledge.[12] Learners must link their current experiences with those in the past and in the future.[13] The many varieties of integrative learning include integrating skills and knowledge from multiple sources and experiences and applying theory to practice in various settings.[14] Students realised the value of integrating knowledge and skills that they had learnt in their first year with that which they were learning in the current year. Building on information promotes learning and follows the constructivist theory that learning takes place in context. The consultation evoked a deep approach to learning through students seeking to understand the process through integration. Promoting student reflection on their learning processes may enable the successful transfer of these integrated skills to other procedures.[2] Nestel et al.[10] recommend that all tasks in a scenario should be contextualised, requiring students to combine technical, communication and other professional skills.

Supporting the findings of Kneebone et al.,[2] students found the opportunity to integrate valuable communication and procedural skills and believed it was an appropriate learning experience. Consumers of healthcare services are increasingly demanding more considerate communication in healthcare.

This may be achieved, inter alia, by including clinical communication education at all levels of the undergraduate curriculum.[1] In 1983, Newble, quoted by Al-Kadri,[15] observed that assessment drives learning. Since then, this point has been viewed as well proven, despite supportive evidence being fairly limited. Several researchers have aimed to explore the relationship between assessment and learning. Until recently, the effect of assessment on students’ learning was unclear.[16] In this study, assessment drives learning in that students are put under pressure to prepare for the OSCE. Benitez,[17] however, believes that

Research formative assessment – not summative assessment – drives learning.

He makes the distinction that formative assessment is for learning and summative assessment is of learning, the latter being the more appropriate in making high-risk decisions. Assessment not only serves as motivation to learn skills and aid the facilitator in determining what students have learnt, but helps students to identify gaps in their learning.[18] By applying assessment criteria, students self-assess what they know, or have done, and what they need to know or do next.[19] Students who are learning to judge the quality of their work against well-defined criteria ‘are developing invaluable skills for lifelong learning’.[20] Curriculum developers should be encouraged to consider the influence of assessments on what and how their students learn.[10] Every experience evokes emotions, which is an important factor that affects thinking.[20] Emotion may in some cases be facilitative, but it may also impede learning.[21] As this was the participants’ first experience of a simulated consultation, it seemed obvious that students’ emotions were more likely to be anxiety and stress rather than a sense of enjoyment.

Students can learn and perform better when feeling excited about the subject matter,[22] but anxiety may distract students’ learning efforts by interfering with their ability to attend to tasks, as was reported by some participants. In some situations, emotions may influence the attentional processes, while in others they may directly influence the encoding and decoding of information.[21] Students in this study experienced stress and the desire to cope with the situation. Epstein[23] believes that once one has recognised negative emotions leading to maladaptive behaviours, one can implement strategies to gain control of those emotions. This corresponds to Sylwester’s[24] belief that students can learn how and when rational processes may be used to override their emotions, or to hold them in check. Sylwester also points out that activities that evoke emotions, such as simulations, may provide ‘important contextual memory prompts’ that will be helpful in recalling information during closely related events ‘in the real world’.

Conclusion

Conducting an OSCE during which preclinical medical students were required to integrate their separately acquired procedural and communi­ cation skills in a simulated consultation, showed a deep divide between these two sets of skills. The poor performance in communication skills compared with procedural skills was repeated in the re-assessment. This may have been the detrimental effect of procedural and communication skills being taught and assessed separately and not in context. It is an indication that communication skills are neglected when teaching procedural skills and that the average student is not able to integrate these skills without practice.

It appears that learning took place during this assessment and reflection event. Students learned from an authentic consultation: they integrated

their procedural and communication skills and their knowledge and skills, they experienced the assessment as learning, and they became aware of the impact of emotion on their learning.

Acknowledgements. I would like to thank all the facilitators from the Skills Centre and the lecturers from the Practice of Medicine Division Centre, University of Limpopo (Medunsa Campus) who participated in the study. A special word of thanks to Dr Verona Sukrajh for help in identifying reflection themes and valuable comments with regard to the protocol and manuscript, and to Prof. Herman Schoeman, who did the statistical analyses.

References 1. Brown J. Clinical communication education in the United Kingdom: Some fresh insights. Acad Med 2012;87(8):1101-1104. [http://dx.doi.org/10.1097/ACM.0b013e31825ccbb4] 2. Kneebone R, Kidd J, Nestel D, Asvall A, Paraskeva P, Darzi A. An innovative model for teaching and learning clinical procedures. Med Educ 2002;36(7):628-634. [http://dx.doi.org/10.1046/j.1365-2923.2002.01261.x] 3. Kneebone R, Nestel D, Yadollahi F, et al. Assessing procedural skills in context: Exploring the feasibility of an Integrated Procedural Performance Instrument (IPPI). Med Educ 2006;40(11):1105-1114. [http://dx.doi. org/10.1111/j.1365-2929.2006.02612.x] 4. Merriam-Webster Online Dictionary. Metacognition definition. 2012. http://www.merriam-webster.com/ dictionary/metacognition (accessed 26 July 2013).

5. De Vos AS, Strydom H, Fouché CB, Delport CSL. Research at Grass Roots. Pretoria: Van Schaik, 2011.

6. UNT Health Centre for Learning and Development Assessment – measurement tools. http://www.hsc.unt.edu/ departments/cld/MeasurementsTools.cfm (accessed 17 May 2013).

7. Neal JM, Hsiung RL, Mulroy MF, et al. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Region Anesth Pain Med 2012;37(1):8-15. [http://dx.doi.org/10.1097/ AAP.0b013e31823d825a] 8. Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory.

3rd ed. Los Angeles, CA: Sage, 2008.

9. Herrington T, Herrington J, eds. Authentic Learning Environments in Higher Education. Hersley, PA: Information Science Publishing, 2006.

10. Nestel D, Kneebone R, Nolan C, Akhtar K, Darzi A. Formative assessment of procedural skills: Students’ responses to the objective structured clinical examination and the integrated performance procedural instrument. Assessment and Evaluation in Higher Education 2011;36:171-183. [http://dx.doi.org/10.1080/02602930903221469] 11. Walker S, Armstrong KJ, Jarriel AJ. Standardized patients. Part 4: Training. International Journal of Athletic Therapy and Training 2011;18(2):20-23. http://www.academia.edu/1136199/Standardized_Patients_Part_4_ Training (accessed 29 July 2013).

12. Kolb AY, Kolb DA. Learning styles and learning spaces: Enhancing experiential learning in higher education.

Acad Manag Learn Educ 2005;4(2):193-212. [http://dx.doi.org/10.5465/AMLE.2005.17268566] 13. Rogers C. Defining reflection: Another look at John Dewey and reflective thinking. Teachers’ College Records 2002;104(4):842-866.

14. Association of American Colleges and Universities (AACU), Carnegie Foundation for the Advancement of Teaching (CF). A statement on integrative learning. Integrative Learning: Opportunities to Connect, March 2004.

15. Al-Kadri HMF. Does assessment drive students’ learning? PhD. Maastricht University, the Netherlands. http:// arno.unimaas.nl/show.cgi?fid=25484 (accessed 7 August 2013).

16. Norman G, Neville A, Blake JM, Mueller B. Assessment steers learning down the right road: Impact of progress testing on licensing examination performance. Med Teach 2010;32(6):496-499. [http://dx.doi.org/10.3109/0142 159X.2010.486063] 17. Benitez J. Does assessment drive learning? Academic life in emergency. 2013. http://academiclifeinem.com/doesassessment-drive-learning/ (accessed 3 August 2013).

18. Prozesky D. Assessment of learning. Comm Eye Health 2001;14(38):27-28.

19. Organisation for Economic Co-Operation and Development (OECD). Formative assessment: Improving learning in secondary classrooms. Policy brief. 2005. http://www.oecd.org/edu/ceri/35661078.pdf (accessed 23 July 2012).

20. Darling-Hammond L, Orcutt S, Strobel K, Kirsch E, Lit I, Martin D. Feelings count: Emotions and learning.

The Learning Classroom 2013:89-95. http://www.learner.org/courses/learningclassroom/support/05_emotions_ learning.pdf (accessed 6 August 2013).

21. Pandey R. How do emotions aid in the learning process? Cognitive science and artificial thinking. 2012. http:// www.researchgate.net/post/What_emotions_do_in_learning_process (accessed 23 July 2012).

22. Oatley K, Nundy S. Rethinking the role of emotions in education. In: Olson D, Torrance N, eds. Handbook of Education and Human Development: New Models of Learning, Teaching and Schooling. Cambridge: Blackwell, 1996.

23. Epstein B. How emotions affect learning. Horizon Academy. http://www.horizon-academy.org/SiteResources/ Data/Templates/t2.asp?docid=659&DocName=How%20E (accessed 23 July 2013).

24. Sylwester R. How emotions affect learning. Educ Leadership 1994;52(2):60-65. http://www.ascd.org/ publications/educational-leadership/oct94/vol52/num02/How-Emotions-Affect-Learning.aspx (accessed 3 August 2012).

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Research A faculty-led solution to transport-related stress among South African medical students S Schoeman,1 MB ChB, MMEd, PhD; G van Zyl,2 MB ChB, PG Dip in Health Administration and Community Health, MFamMed, MBA, PhD; R A Smego (deceased),3 MD, MPH, FACP, FRCP, DTM&H 1

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

2 3

School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Corresponding author: S Schoeman (schoemanfhs@ufs.ac.za)

Background. In many parts of the developing world the lack of consistent and affordable transport may be a serious obstacle to education and a unique sociocultural cause of stress among undergraduate students.

Objective. To determine the student-perceived benefits of a faculty-led, grassroots student transport service for economically disadvantaged medical students. The service has been newly developed and implemented at the School of Medicine, University of the Free State, Bloemfontein, South Africa.

Methods. A brief qualitative questionnaire survey, with Likert scales and free text, was administered to participants in the Student Transport Project after its first 21 months of operation. Students’ views of the impact and effect of the project on their circumstances were surveyed.

Results. During its first 2 years of operation, the Student Transport Project was used by 116 students in their clinical third - fifth years, representing 16.6% of students in these years of training. All the participating students using the shuttle service were from previously disadvantaged communities and were economically disadvantaged. A survey among the participating students yielded an 84% response rate; they all felt that the service significantly reduced their levels of financial and emotional stress, and many believed that the project positively impacted on their academic performance and assisted them in remaining in medical school.

Conclusion. The basic, but novel, student transport service described in this article can have a dramatic effect in reducing medical student stress and, potentially, improving academic performance and success. It is hoped that others in lesser-developed countries in Africa and beyond may replicate such a student-centred transport initiative at their schools.

Afr J Health Professions Educ 2015;7(2):170-175. DOI:10.7196/AJHPE.352

Stress among medical students is a universal cross-cultural phenomenon with many risk factors.[1-12] Causes of stress include exogenous, endogenous, academic and non-academic factors.

Stress and distress among medical students may lead to physical, psychological and academic difficulties; damaging effects on empathy, ethical conduct, and professionalism; personal consequences such as substance abuse, broken relationships, and suicidal ideation; and also contribute to burnout and dropout.[13-15] Examples of institutionally provided medical stu­ dent support services directed at reducing stress include counselling, wellness programmes, cognitive behavioural approaches, and peer mentor programmes.[16-18] Transport challenges were recently highlighted as a major source of stress among medical and allied healthcare students.[19] In this article we describe the lack of personal transport as a major and prevalent sociocultural cause of stress among underprivileged South African (SA) medical students. Furthermore, we present our practical experience and offer some financial information with regard to developing and implementing a student transport service for economically disadvantaged medical students at the University of the Free State (UFS), Bloemfontein, SA. It is hoped that other medical schools may find the data and information helpful to replicate a similar student-centred transport initiative aimed at alleviating financial and emotional pressures, which may have a positive effect on medical students’ academic performance. We used ‘underprivileged’ and ‘economically disadvantaged’ interchangeably and defined these terms as a student group who, compared with their privileged or economically advantaged class peers with adequate financial means to enable easy

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access to private transport (a car), is forced to use the costly, untimely and dangerous public transport system in our city to commute between the hospitals of our training platform.

Before the inception of this project, underprivileged students without access to private transport had to rely on expensive, untimely and sometimes dangerous public minibus taxis to commute between the five different clinical sites of the UFS medical school training platform. During the preproject needs analysis, students reported that their annual cost to use public minibus taxis solely for their medical training needs was between ZAR5 000 and ZAR5 500. This led to undue and added financial, emotional and academic stress owing to the additional logistical pressures. Many of them were struggling to cope with the academic demands of their medical studies. Virtually all of the participating economically disadvantaged students have bursaries; hence, they have very little money left to pay for out-of-pocket expenses of local taxi transport. Some students reported that they often had to decide between affording the cost of travelling and having a meal.

Institutional background

The 110-year-old UFS is 1 of 24 public universities in SA, of which 8 (including the UFS) have medical schools. With its 8 faculties (including Health Sciences, comprising schools of Medicine, Nursing, and Allied Health Professions), 3 campuses, and >31 000 students, including >720 medical students, UFS is one of the oldest institutions of higher learning in SA. The School of Medicine (SoM) is situated on the main UFS campus in Bloemfontein, the capital city of the Free State Province. The SoM has a 5-year

Research undergraduate medical curriculum, a parallel language medium of instruction (Afrikaans and English streams of separate language instruction), and uses the 5 medium-to-large state teaching hospitals in the greater Bloemfontein area to deliver its clinical training. The university has a 64% black student body population, while the SoM had the following student body racial demographics during the implementation phase of the project: white or Indian (72%), and black or coloured (28%). The reasons for the difference in overall student racial profiles between the greater UFS and SoM are mainly due to the fixed ratio (50/50) and numbers of first-year students (140) enrolled annually into the medical programme’s parallel-medium language classes (70 in each class) and the relative higher attrition rate of students in the English class. The Afrikaans instruction class is a predominantly white class, with some coloured (mixed race) students, whereas the English class is largely constituted of ethnically black African, Indian and coloured students, with some white students. Transport challenges and related stress were identified as a possible contributing factor to the higher attrition rate in the English class groups – this was a motivating factor to develop this project.

Project description

The project is housed in the SoM. The Phase III Committee, which administers the clinical phase of the MB ChB (medical) programme, is the curricular committee that oversees the project under the leadership of the project’s academic managers, operational lead (the first author), and chair of the Phase III Committee. Other project personnel include an administrative officer as secretary for the Phase III Committee. She also manages the project on a day-to-day basis and deals with all the related administrative matters. She reports to the academic project manager, and together they run the operational side of the project. Students wishing to use the service must complete and sign the project application and indemnity form before a semester ticket is issued.

The cost of a semester ticket, which is heavily subsidised by corporate sponsors, is billed to the UFS student accounts system of the relevant student. This was an important step and a huge help from the university, because the billing method enables the bursary providers to cover the transport cost, as it is viewed as an official student expense. To keep the administrative load regarding tickets and access to the project manageable, students must commit for an entire semester.

If they wish to leave or join the project during the semester, the cost of the ticket remains unchanged and no refunds are issued. This strategy has proven to be very successful, as it encourages students to make informed and well thought through decisions at the start of each semester with regard to joining or leaving the project, and discourages ad hoc users.

The project is funded from two sources: corporate donors and the participating students’ bus ticket sales each semester. The start-up funds were provided by three corporate donors: Netcare, a national private healthcare provider, which donated the two vehicles (~ZAR600 000), PPS Financial Services, which gave a ZAR114 000 cash donation, and Pfizer (SA), which donated ZAR57 000.

The Student Transport Project began operating on 11 April 2011. It proved an instant success with regard to easing the transport concerns and problems of the students. It was officially launched on 30 September 2011, with local and national media invited. The students’ elected representatives from each year group (third - fifth year) form part of the project’s management team who keep in touch with their needs and provide feedback on the system. During 2011 and 2012, 59 and 57 students, respectively, were part of the project. Table 1 provides a breakdown of the numbers and percentages of the total annual cohort involved in the project. Although the project is open to all students in the clinical phase of the medical curriculum (final 2.5 years of the 5-year

programme), all (100%) of the students who enrolled for the project were in the English class and black African, Indian or coloured. Therefore, to date, all the students engaged in the project were from previously disadvantaged communities (under the previous Apartheid government) that had no access to private transport.

The cost of the service for students per semester was ZAR1 200 during 2011 (pro rata from April to June) and ZAR1 350 in 2012, which was billed to their individual student UFS accounts. The project team, with funds made available from the SoM Phase III Committee (ZAR24 000), had designated car ports erected for the buses to protect the vehicles from the weather during times when they are not in operation.

Students can hop on and off the bus at any of the hospitals en route. The shuttle service operates 7 days a week and on public holidays. The fourth- and fifth-year medical students use the shuttle during the entire academic year (January - November, i.e. first and second semesters). The third-year students join the clinical phase of their training (Phase III) in the second semester of their third year. Therefore, the project carries more students and makes more weekday trips in the second semester (third - fifth years) than in the first semester (fourth and fifth years only) of each academic year. Table 2 Table 1. Students involved in the Transport Project 2011

2012

Academic year

n

Class cohort, %

n

Class cohort, %

Third

23

19 (23/119)

9

8 (9/118)

Fourth

23

21 (23/107)

32

26 (32/125)

Fifth

13

11 (13/121)

16

15 (16/108)

Total

59

17 (59/347)

57

16 (57/351)

Table 2. Shuttle times for the UFS Student Transport Project Departs from UFS

Back at UFS

Shuttle, n

06h15

07h15

1

07h15

08h30

2

12h00

13h00

2

17h30

18h30

1

22h30

23h15

1

07h30

08h30

1

10h30

11h10

1

22h30

23h15

1

06h15

07h15

1

07h15

08h30

2

11h00

12h00

1

12h00

13h15

2

17h30

18h30

1

22h30

23h15

1

07h30

08h30

1

10h30

11h10

1

22h30

23h15

1

First semester Weekdays

Weekends and public holidays Second semester Weekdays

Weekends and public holidays

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Research provides an illustration of trip times of the shuttle during the respective semesters. The two shuttles conducted 1 021 trips in 2011 and 1 596 in 2012.

A trip is defined as one circle route from the UFS SoM building to the 5 affiliated teaching hospitals in the greater Bloemfontein area, and back to the SoM building.

There are 2 bus drivers who share the transport duties for 7 days a week. Their official work uniform consists of UFS polo shirts and name badges. There are two 15-seat passenger shuttles (minibuses) – both equipped with satellite tracking devices (installation cost ZAR7 000 and annually ZAR7 000 for licences) that provide information regarding the whereabouts of the buses at all times and log the information of every trip. Project data are kept on the tracking company’s server for 6 years. The drivers were paid ZAR60 per completed trip in 2011. Their fee is raised annually in line with UFS inflation salary adjustments. The project’s administrative manager receives a small monthly stipend for being ‘on call’ after hours if problems should arise. The total operational costs for the project in the 21 months of operation were ZAR386 640.

The project ended in 2012 with a positive balance of approximately ZAR160 000, which provided sufficient operating capital to continue with the project into 2013.

The project also developed a standard operating procedure (SOP) for the 2 drivers (Appendix A).

Copies signed by the drivers are kept on file.

Students are also aware of the SOP, as it is placed on Blackboard®, the school’s educational management system. Keys to the buses are kept securely in a combination safe in the SoM when the buses are not in use. Because of the operating hours described in Table 1, the drivers have electronic access cards to enable them to enter the SoM building after hours to fetch and return the keys before and after each trip, respectively.

Methods

The students who took part in this research study signed consent forms so that the authors may use their data and publish the findings. The UFS Faculty of Health Sciences Ethics Committee approved the study (Ethics Committee No. ECUFS 33/2013).

The research questions for this study were: (i) How many students are using the Transport Project; and (ii) What was the perceived impact of the Transport Project on the participants of the project with regard to their finances, stress levels, academic performance and wellbeing?

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We reviewed our project registration forms to calculate the number of students using the project annually and invited all of them to complete a simple and quick self-administered Likert-scale questionnaire to evaluate the impact and effect of the project. The students could also add some free text comments to elucidate their responses.

The survey (Appendix B) was circulated during December 2012 to the graduating fifthyear students (n=16) and in the first semester of 2013 to the students involved in the project at that stage (n=40). Therefore, a total of 56 student participants were invited to take part in the study.

Results

During its first 2 years of operation, the Student Transport Project was used by 116 students in their clinical years 3 - 5, representing 16.6% of students in these years of training during 2011 2012 (Table 1). The response rate for this study (survey component) was 84% (47/56).

The results of the student survey of the perceived impact and effect of the project are shown in Table 3.

Table 4 reports on selected student testimo­ nials with regard to the Student Transport Project during its first 21 months of operation.

Discussion

The project represents a student-centred, facultydriven grassroots initiative that developed as a result of a faculty-perceived student need.

Although it is explicitly stated in the regulations

of our medical programme that transport arrangements between the SoM and our various training platform hospitals are the responsibility of individual students, the faculty members at the UFS SoM recognised that many of the students do not have the personal financial means for transport costs. Hence, we see this project as an outflow of our social responsibility to support our economically disadvantaged students to succeed in medicine.

Within the first 21 months of operation, the Student Transport Project has become a notable and visible institutional success. It is available to clinical medical students who require it; however, it is not a personalised system for individual participants. The participating students’ responses to the project have been overwhelmingly positive.

The data from Tables 3 and 4 show that the Transport Project had a positive influence on their academic experience and performance.

Furthermore, students reported that the service significantly reduced their levels of financial and emotional stress, and many believed that the project helped them to remain in the medical programme. The perception that faculty members in the SoM care about the welfare and difficult circumstances of many of the participating students was enhanced by the project (Tables 3 and 4), which is helpful for fostering positive staffstudent relationships in the medical school.

From Table 1 it is evident that only a subgroup of students use the service and that most students do not need the project to facilitate their

Table 3. Perceived impact of Transport Project Statement number

Rated statement

Mean Likert scale finding* (n=47)

1

Overall, the Student Transport Project has positively influenced my medical school experience.

4.6/5

2

The Student Transport Project has helped alleviate financial pressures for me.

4.6/5

3

The Student Transport Project has helped alleviate emotional/ psychological pressures for me.

4.2/5

4

I feel that the Student Transport Project has had a positive impact on my academic performance at UFS.

4.1/5

5

I feel that the Student Transport Project has been a major factor in allowing me to stay in medical school.

3.7/5

6

I feel that the Department of Medicine is truly concerned for the wellbeing and success of students.

4.7/5

7

I believe that the Student Transport Project would not have been created without the concern and support of the faculty in the Department of Medicine.

4.7/5

*Based on a Likert scale of 1 - 5 (lowest to highest level of agreement) – see Appendix B for details.

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Research

Table 4. A selection of individual student narratives on the impact and effect of the Transport Project • This project helps us to have safe and reliable transport. This project is most valuable during the evening especially for the female students.

• This has been a great help to me and I just want to thank Internal Medicine Department, the dean and all the corporate sponsors for keeping this initiative going.

• Thank you very much for making our academic experience easier. We saw out serious previous struggle with transport and we were very worried.

• It is important to keep this transport project going because it is very important to people like us without cars and also makes us stress free.

• This project has helped me a lot with regards to participate at the hospital and also the lectures. I am always on time and I manage to prepare my work and patients on time. Thank you.

• This project has relieved a lot of pressure on me as a student, it is highly beneficial and important.

• The Transport Project has been very helpful, it wouldn’t have been possible for some of us to travel between the hospitals. Thank you very much!!

• The Student Transport Project is a very helpful transport system to those with no personal transport. It is important that even in the upcoming generation the system stays in use.

• I was one of the students who used to use public minibus taxis and I really appreciate and am thankful every day that the project was started and continues. Thank you.

• Thank you very much for your efforts, I cannot imagine how I would have managed to go and come back from hospitals at night (23h00), really personally you have helped me a lot. Please no matter what, do not stop helping us, we really truly appreciate. Thank you once more.

• It has truly alleviated the stress and we’ve been able to safely travel between the faculty and hospital. It has especially helped us in regard of our evening calls that end at 23h00.

• I don’t have a car and the Transport Project has at least alleviated that stress because I no longer worry about how I will get to Pelonomi/National hospital.

The amount we pay is very reasonable considering it’s for 6 months. On Saturdays and Sundays, it will be nice if there was transport that leaves at 17h30 as well, as well as on public holidays. All in all, Transport Project is a real great help!!

• The staff of the Student Transport Project is very accommodating and concerned about our wellbeing. It is an absolute pleasure to work with them. The project has been a great help to a lot of us, especially financially. It is not a lot of us students who have cars and having the Transport Project – it takes some pressure off.

• I do not know how I would have worked without the Transport Project. Some of the time you finish working at 11pm and you do not have money to call a private taxi.

Also, we are very grateful for the shuttle drivers, they are very understanding when sometimes we are released late from the call they always wait for us. Thank you very much.

transport needs. Students who are not using the project presumably prefer to use their own cars or make use of ‘lift-clubs’ with fellow students. Both of these options are probably more expensive, as they are not subsidised by corporate donors, but they are more personalised and convenient. However, the SoM realises that this does not imply that they are without some of the same stressors (e.g. finances and academic pressures) that the project students experienced.

Although this study did not directly measure the number of students without access to routine private transport for their medical training needs, and given the negative aspects outlined in this article about the public transport system in Bloemfontein, the study does give a good indication of the percentage of senior medical students (16.6%, Table 1) in our medical school who are reliant on travel support to meet their medical training needs.

Student affairs and financial aid offices at medical schools typically provide a range of academic and personal support services designed to help students succeed; these may play a crucial role in aiding students to stay in the academic programme. In the developed world, one does not usually consider student transport as a significant source of student stress and hardship[6] because of the ability of students to provide their own transport or the availability of adequate public transport. In much of the developing world, however, a lack of consistent or affordable transport may be a real obstacle to successful employment and education.[19] As educators, our ultimate goal is the success of the medical students in becoming competent and caring physicians. Our efforts in curriculum development and student supervision and assessment are directed towards realisation of this goal. At times, however, the success of students becomes critically dependent on non-educational efforts that take place outside the classroom or clinical arena. The role of non-academic student supportive

services is often overlooked when evaluating the educational success of students. The kind of basic, but novel, student transport service described in this article may be helpful in reducing medical students’ stress and, potentially, improving academic performance, as suggested by the students’ feedback in this research project.

Acknowledgement. We acknowledge the important role and support of our corporate partners towards this project and in assisting future medical doctors in southern Africa – Netcare; PPS Financial Services; and Pfizer (SA).

We also acknowledge the efforts and drive of the late Professor Raymond Smego junior to publish this article and make this project known to healthcare professionals. He sadly passed away in December 2012.

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17. Barker TA, Ngwenya N, Morley D, Jones E, Thomas CP, Coleman JJ. Hidden benefits of a peer-mentored ‘Hospital Orientation Day’: First-year medical students’ perspectives. Med Teach 2012;34(4):e229-e235.

18. McGrady A, Brennan J, Lynch D, Whearty K. A wellness program for first year medical students. Appl Psychophysiol Biofeedback 2012;37(4):253-260. [http://dx.doi.org/10.1007/ s10484-012-9198-x] 19. Omigbodun OO, Odukogbe AA, Omigbodun AO, Yusuf OB, Bella TT, Olayemi O. Stressors and psychological symptoms in students of medicine and allied health professions in Nigeria. Soc Psychiatry Psychiatr Epidemiol 2006;41(5):415-421. [http://dx.doi.org/10.1007/s00127-006-0037-3]

Appendix A. Standard Operating Procedures for shuttle DRIVERS UFS School of Medicine Transport Project Version 3. 1 August 2012 (valid for 1 year – August 2013) 1. Drivers must under NO circumstances deviate from the normal prescribed route. This exposes the shuttles to possible theft and hijackings. Shuttles are fitted with GPS tracking devices and checks are done regularly. Regarding the 23:00 drop-off, you may drop particular students who paid the extra ‘home drop fee’, close to their homes. The other students must be dropped on the prescribed route.

2. Drivers are to ENSURE that they themselves and ALL passengers wear seatbelts at all times when the shuttle is in operation.

3. Drivers must NEVER drive faster than 60 km/h, except if it is a case of extreme urgency and must report this to Mrs Nel or Dr Schoeman on the first working day after the incident.

4. Drivers MUST follow the road rules and drive politely and never drive recklessly or in a manner that causes discomfort to any passenger. Passengers are encouraged to report good and bad driving.

5. NEVER stop in the street to pick up or drop off a student.

6. Drivers must NEVER talk on their cell phones while driving the bus. Please ask a student to answer your phone. It’s illegal to talk on a mobile phone and drive.

7. Drivers must log trip details in logbook before and after each trip.

8. The logbook and drivers rota are used to calculate remuneration on a monthly basis.

9. When no students arrive for the trip at the different pick-up points, park the bus and complete the log book. The Tracker system will indicate movement of the shuttle and remuneration will only be paid when the UFS pick-up route is completed.

10. Drivers must report damage to the shuttle immediately upon return to the faculty (next day if after hours) AND inspect vehicle before he takes responsibility for it, otherwise he will be held responsible.

11. Drivers MUST collect and replace the keys to the shuttles in the security safe provided by the project. Tags and codes to the safe must NEVER be shared with ANY other person outside of the project team (i.e. drivers and management team – Dr Schoeman and Mrs Nel).

12. Drivers MUST check the validity of students’ tickets BEFORE admitting them on the shuttle.

13. Drivers must ensure the neatness of the interior of the shuttles and report to management if students are messy in the shuttles.

14. In case of a hi-jack, press the panic button if possible. Co-operate with the hi-jackers and do not put yourself or the passengers’ (if any) lives in danger.

15. If you are suspicious of someone following you, try to get the licence plate number or description of the car and report it to the nearest police station.

16. Defer all students’ special requests to Dr Schoeman or Mrs Nel. 17. An up-to-date list of all the students participating will be available in each shuttle.

18. Regarding the petrol cards: 18.1 The card may only be used for the vehicle identified on the card.

18.2 Please make use of the Bloemgate service outlet in Nelson Mandela Drive.

18.3 Always check that the card you receive back is yours.

18.4 Report a stolen or lost card immediately to Mrs Nel. 18.5 Check that the slip is printed clearly and give it to Mrs Nel who will file it.

Please take note: Drivers who transgress these SOPs will be subject to disciplinary procedures and could face possible dismissal.

Signed: at _______________________ on ____________________20_____ Name and surname:________________Signature: __________________ Dr F H S Schoeman:_________________Admin officer: _______________

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Appendix B. Student questionnaire about the Student Transport Project School of Medicine Key 1 = Strongly disagree

2 = Disagree

3 = Uncertain

4 = Agree

5 = Strongly agree

Student Transport Project survey • Overall, the Student Transport Project has positively influenced my medical school experience 12345 • The Student Transport Project has helped alleviate financial pressures for me 12345 • The Student Transport Project has helped alleviate emotional/psychological pressures for me in relation to my medical studies 12345 • I feel that the Student Transport Project has had a positive impact on my academic performance at UFS 12345 • I feel that the Student Transport Project has been a major factor in allowing me to stay in medical school 12345 • I feel that the Department of Internal Medicine is truly concerned for the wellbeing and success of students 12345 • I believe that the Student Transport Project would not have been created without the concern and support of the academic staff in the Department of Internal Medicine 12345 Additional comments:

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Research Nursing students’ perception of simulation as a clinical teaching method in the Cape Town Metropole, South Africa N Nel, BCur, MCur, PGND: Health Assessment, Treatment and Care, PGND: Management, PGND: Education; E L Stellenberg, DCur, RN, RM Division of Nursing, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: N Nel (natalievdmerwe@sun.ac.za)

Background. Given the pivotal role that simulation plays in teaching students clinical skills, it is important to understand the students’ perception of using simulation laboratories.

Objectives. A descriptive qualitative research design was used to determine whether participants ‘believe’ they have gained competence and confidence to assess a patient holistically.

Methods. Purposive sampling of 10 individual interviews and a focus group of 7 participants was drawn from primary healthcare students who successfully completed the programme the preceding year. Data were collected by 2 trained fieldworkers and transcribed by the researcher (NN).

Ethical approval was obtained from the Health Research Ethics Committee, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, and informed consent from the participants.

Results. The data that emerged from the data analysis were coded and categorised into themes and subthemes. The following 5 themes emerged: simulation as a teaching method; a manikin offering effective learning; confidence in clinical practice; structure of the course; and a support system.

The researcher compiled a written account of the interpretations that emerged from the data analysis and verified these with the fieldworkers.

Furthermore, member checking was done on 2 of the participants from the focus group and 2 of those from the individual interviews to validate the transcribed data. The findings suggest that the manikin should be upgraded regularly and be able to register a response. Data showed that the students are in favour of simulation as a foundation phase in their programme, but preferred to be introduced to a human being.

Conclusion. Simulation as a clinical teaching method ensured a good foundation phase, but students felt more competent and confident after practising on humans.

Afr J Health Professions Educ 2015;7(2):176-179. DOI:10.7196/AJHPE.363

The confidence and competence levels of primary healthcare (PHC) nurse specialists are essential skills that are required when assessing a patient holistically. The PHC nurses need excellent clinical skills and require basic knowledge to think critically and analytically. Good confidence and competence levels will enable these specialists to think beyond the normal practice, be creative and innovative in finding better ways to assess and manage their patients, and ensure a safe and cost-effective practice. For PHC nurses to be confident and competent when assessing a patient, it is suggested that they are taught in a student-centred environment.[1] Moreover, to ensure that PHC students are eventually safe and competent practitioners, it is essential that they develop their skills by practising and be declared competent before working in a clinical setting. By practising their clinical skills as a learning strategy, the students simultaneously improve their levels of competence and confidence. It was observed in the clinical field that if the confidence and competence levels of the PHC nurses are inadequate when assessing patients, they are unable to assess the patient effectively and holistically.

It is a concern when assessing a patient in the clinical field, as the safe management of patients may be seriously compromised.

‘Simulation is an approach to teaching and learning which is defined as a device that presents as a simulated patient (or part of a patient and interacts appropriately with the actions taken by the simulation practitioner).’[2] Educators have suggested that active learning and student participation produce better educational outcomes.[1] According to Langlois and Thach,[3] there is no single way of teaching in a clinical setting. Clinical teachers may adapt their styles to reflect the situations that arise. However, various

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educationalists describe approaches to learning in the cognitive, affective and psychomotor domains by emphasising Bloom’s Taxonomy.[4] Larkin and Burton[5] further argue that using the framework of Bloom’s Taxonomy of Educational Objectives assists staff members to critically evaluate the patient’s scenario to prevent future patient complications. It measures the cognitive, affective and psychomotor domains.

Bloom’s Taxonomy has long been the average framework among clinical nurse educators and staff development co-ordinators for designing learning experiences, thus providing general guidance in the development of learning objectives.[6] Ming Su et al.[7] state that the revised Bloom’s Taxonomy provides a framework to help educators to clarify their proposed objectives and design suitable education and assessment methods. Furthermore, Harton[6] states that learning in each domain builds on previously acquired knowledge – from simple to complex. According to Meyer and Van Niekerk,[4] achieving the ultimate level in each domain depends on mastering previous levels. Students may not be able to solve problems if they do not know what the problem involves or how to go about solving it. Therefore, educators must systematise the actions for students so that they are able to carry them out. The planned systemisation guides educators in selecting teaching and assessment strategies.[4] The use of a human patient simulator (HPS) provides a method by which students can participate in clinical decision-making, practise skills and observe outcomes from clinical decision-making.[8] According to Brannan et al.,[8] it was anticipated that the use of the HPS may develop students’ cognitive skills and clinical confidence levels. It is important that students are fully prepared when assessing and examining patients. Bloom’s Taxonomy is the focus of cognitive, affective and psychomotor domains, which are essential approaches to learning.[4]

Research Lamb[9] substantiates that students’ clinical confidence may increase with simulator experience, as simulation enables the student to practise skills before working with patients. To ensure that PHC students eventually become skilled and competent practitioners before entering the clinical field, it is essential to develop their skills by practising. The principal investigator (PI) observed – in the clinical field – that if the confidence and competence levels of the PHC nurses are inadequate when assessing patients, they are unable to assess patients holistically. A PHC nurse working in a clinical field must be able to apply the necessary skills and knowledge required when assessing a patient holistically. Haigh[10] argues that simulated practice in university settings offers the potential for reflection and deep learning. A deep approach to learning is student centred and involves a search for understanding. Students must therefore think actively about what they are doing. One of the elements that fosters a deep approach is active learning, where the student is actively involved.[4] Clinical simulation is a method of active learning that offers students a wide range of learning opportunities, including ways of applying theory to practice by bringing principles learned in the classroom to life.[1] By using simulation as a teaching method, it prepares students to face real-life situations. According to Stefanski and Rossler,[11] simulation has come to the forefront as an effective teaching modality in teaching the science of nursing. It is important that students are fully prepared when assessing and examining patients. However, the PI observed that PHC students studying at our university failed to adequately acquire the required clinical confidence and competence to assess the ‘real’ patient. At this university these students predominantly practised and acquired their clinical skills with laboratory simulations. Many students verbalised that they did not feel competent or confident to assess patients holistically after having practised on artificial manikins. This raised serious concerns for academic lecturers who applied this teaching and learning strategy, as ultimately patient safety might seriously be compromised.

This study explored the perceptions relating to the use of laboratory simulation, a method applied to teach clinical skills to postgraduate PHC students to specifically develop their clinical confidence and competence levels as required of PHC nurses in clinical practice.

safety. It therefore became imperative that a scientific investigation be undertaken to explore the perceptions of postgraduate PHC students who used simulation laboratories as a learning strategy.

Purpose of the study

Credibility Credibility was assured by being satisfied that the participants understood the questions well and agreed to the accuracy of the transcribed data.

Member checking was done with 2 of the participants from the focus group and 2 from the individual interviews to have the transcribed data validated.

The first level of care, according to the PHC policy applicable in South Africa (SA), prescribes that it should be managed by PHC nurses without the support of medical practitioners.[12] Access to quality public services is the rightful expectation of all SA citizens.[12] Most of these citizens are employed in a no-work, no-pay service and therefore expect an effective and efficient service. By completing this study, the appropriate learning strategy was identified and applied to produce confident and competent PHC nurses to ultimately ensure an effective and efficient service in PHC. The purpose of this article is therefore to describe the research based on the perceptions of students who followed the PHC postgraduate programme at a selected university in SA. As part of developing clinical competence and confidence, these students were first exposed to the use of the simulation laboratory before they had any clinical encounter with a patient.

Problem statement

With regard to the discussion above, the low confidence and inadequate competency levels demonstrated by PHC students in the clinical field, despite their interaction in a simulation laboratory, may compromise patient

Research question

The following research question guided the study: ‘What are the perceptions of postgraduate PHC students utilising simulation laboratories as a clinical teaching method?’

Objectives were set to determine whether participants ‘believed’ that they had gained competence and confidence to assess the patient holistically.

Methods

Research design and sample

This study followed a descriptive qualitative approach that explored the perceptions of postgraduate PHC students who were taught clinical skills utilising simulation laboratories. The target population comprised parttime PHC students who obtained the Diploma in Primary Health Care in 2010 at the university chosen for the purpose of this study in the Cape Town Metropole in SA. This university was selected purposefully as it enrolled an average of 120 students per year who followed a postgraduate diploma in PHC. This university specifically used simulation laboratories as a teaching method to teach clinical skills to these students. A purposive sample of 10 individual interviews and a focus group of 7 participants was drawn from this population of successful students. These students were purposively selected to ensure the variability of the sample. More participants would be drawn should data saturation not be achieved after the 10th interview. Data saturation was met after these interviews.

Pilot study A pilot study was conducted on one of the participants to test the feasibility of the study; these results are not included in this study.

Trustworthiness The trustworthiness of this study was established according to Guba and Lincoln.[13]

Transferability A conceptual theoretical framework based on Bloom’s Taxonomy and the use of more than one method of data collection strengthened transferability.

Dependability Dependability was assured by the use of a tape recorder to ensure that all the information given by the participant was recorded. A second fieldworker took notes during the interviews with the participants. All interviews were conducted in the same manner by using an interview guide. The data were transcribed and analysed after each interview and verified by a fellow researcher, 2 fieldworkers who collected the data, and an expert in qualitative research. The researcher and fieldworkers discussed the transcribed data and clarified differences of opinion to ensure that the

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Research interpretation of the transcripts was congruent with the recorded interview.

The analysis of the data and the themes and subthemes was further verified by the supervisor of the researcher.

Conformability Member checking was done. Hence, the participants in this study were given an opportunity to be informed of the results of the study and make further recommendations. The participants, however, did not make any further recommendations.

Data collection

An interview guide was designed based on the objectives of the study, the literature review and the researcher’s professional experiences. Two trained fieldworkers were responsible for collecting the data to prevent bias, as the researcher is a lecturer at the university. Participants were quoted verbatim in the transcriptions, as it assisted in confirming the data collected. Thereafter, the researcher read and reread the transcriptions. One of the fieldworkers had a guideline with open-ended questions, which guided the interviews in order to collect the data. The fieldworker conducted the interviews in the university’s seminar room – in agreement with the participants. The participants gave signed permission that the interviews could be recorded with the use of a tape recorder. The second fieldworker, a PHC nurse, had no role in the interviewing of the participants but documented and recorded the interviews.

Ethical considerations

Consent was obtained from each participant for taking part in the study and the use of audio- and written recordings of the interviews. The participants were assured of anonymity. Permission to conduct this study was obtained from the Health Research Ethics Committee, Faculty of Medicine and Health Sciences, Stellenbosch University. All ethical principles were adhered to. Data are locked and stored in a safe place for at least 5 years – only the PI has access to the safe.

Data analysis

The transcription of the interviews was done by the researcher to familiarise herself with the data. In this manner she became familiar with the data as these were gathered. Data were analysed according to Tesch’s[14] 8-step model. The data that emerged from the data analysis were coded and categorised into themes and subthemes. Coding, elaboration and recording continued until no new insights appeared. The written account of the interpretations that emerged from the data analysis was verified with the fieldworkers.

Presentation of findings

The first theme was labelled ‘Simulation as a teaching method’, where participants spoke willingly about their perception of simulation during their 1-year postgraduate diploma in PHC studies. A number of participants stated that the use of simulation prepared them for what to expect in the clinical setting.

‘It helped me a lot, it gave me an idea how to start and where to start … .’ ‘ … for me I would say that simulation was the foundation of, … but not the ultimate.’

The second theme related to ‘A manikin offers effective learning’. The use of a manikin is one of the simulation methods the students were exposed

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to – they felt that the manikin was outdated. They also thought that communication was a very important aspect and wanted ‘something’ to communicate with them. They expressed the need to be exposed to different anatomical challenges of human beings before entering the clinical field.

‘With a doll, you don’t know are you working too rough or too soft, because the doll can’t tell you that, they can’t communicate.’

The third theme was ‘Confidence in clinical practice’. Participants indicated that they gained confidence when exposed to practising on human beings.

Even though they practised repeatedly on manikins, their confidence developed slowly. A few of the participants stated that their confidence developed with time. It took them a few months of practising to be confident enough to examine a patient.

‘I practised on my family and that gave me confidence cause you interact with a person while you learn.’

The fourth theme was the ‘Structure of programme’. When asked whether it was feasible to use simulation in PHC, all 17 participants agreed that it must be used. They verbalised the need to interact with patients at an earlier stage; hence the reason why they did not find the manikin effective as a clinical teaching method.

‘If I had a choice then I would have wanted the practical to start in the clinics.’

The fifth theme consisted of the ‘Support system’. Simulation is a good starting point; however, students expressed the need to be introduced to a human being before entering the clinics. They took the initiative to practise on their family or friends at home to build their confidence. Most of the participants stated that the support and practice sessions among students were wonderful and benefited them in their studies. ‘ ... we were a team, and worked as a team. We helped each other that way, if we forgot something the other one remembered it.’

Discussion

The results have shown that the use of simulation as a teaching method in postgraduate teaching of PHC nurses’ skills is effective to some extent.

It is pivotal that the PHC nurses are well prepared to assess a patient competently and confidently, as the safety of patients’ lives are at stake.

According to Ward-Smith,[15] simulation learning is used to promote clinical competence and reflective thinking skills. The norms and standards set out by the Department of Health[12] emphasise that PHC is at the heart of the strategy to change the health services in SA. An integrated package of essential PHC services available to the entire population will provide a solid foundation for a single, unified health system. PHC nurses, after completion of a postgraduate programme in PHC, become independent clinical nurse practitioners in the SA context and are expected to function without the support of a doctor.

There was much debate among members of the focus group about the use of manikins as a learning method. Some of the participants felt that manikins were not needed, but agreed that they were a good starting point, while most enjoyed working with them. Most of the participants emphasised that they should be introduced to a human being, because the manikins were anatomically ‘perfect’ and differed from human beings, who have excess fat and skinfolds, which are absent in manikins. The participants also

Research found it problematic that the manikin could not communicate verbally and non-verbally, creating a barrier in developing affective skills and obtaining subjective data during an assessment phase – a much-needed requirement when assessing patients.

To develop competence, multiple practice sessions are required to enable a student to competently assess a patient, as this is a gradual process.

Furthermore, competence in assessing patients should include practising on human beings. Positive and negative opinions were obtained from the participants with regard to their perceptions of simulation laboratories.

All the participants finally agreed that simulation is a ’good starting point’ in the clinical programme. Moreover, they referred to simulation as a foundation phase that prepares them for what to expect when working with a patient. The participants felt that the use of simulation is positive in a clinical programme, but would have preferred to be introduced to a human being before working with patients, as the human being made them feel more confident. The use of an HPS provides a method by which students can participate in clinical decision-making and practice skills and observe outcomes from clinical decision-making.[8] According to Brannan et al.,[8] it was anticipated that the use of the HPS may develop students’ cognitive skills and confidence levels. The cognitive domain involves knowledge and development of intellectual skills, including the recognition of specific facts, procedural patterns, and concepts that serve in the development of intellectual abilities and skills.[16] The participants felt that by practising on people individual confidence to assess a patient increased.

The results of the study are supported by Bloom’s Taxonomy. Firstly, the students obtain new knowledge, which is the theory of the programme that forms part of the cognitive domain. To develop competence, theory is applied by practising on the manikin in order to become competent. During the progression of their skills the students develop the affective domain, which does not happen if only simulation is used. During practice sessions the students start contemplating new ways of becoming more skilled and competent, which supports the psychomotor domain.

The study focused on the perception of the postgraduate PHC students utilising simulation laboratories at one university. It excluded other institutions offering a similar programme. The study excluded other disciplines such as medicine and physiotherapy, which also have

a clinical component in their programmes. Further research is therefore recommended in this regard.

Conclusion

The participants in the 1-year postgraduate diploma in PHC perceived the use of simulation laboratories as positive, yet felt that they should be introduced to reality at a much earlier stage of the programme. Practising on human beings as models made them more competent and confident to assess patients holistically in the clinical field. Simulation is an excellent teaching method to prepare the student in terms of what to expect and a starting point for the development of confidence, but the results showed that by practising on a human being prepared them for the clinical setting.

It is suggested that the manikins should be upgraded on a regular basis and match the actual clinical setting. In this manner the use of simulation as a teaching strategy may complement the clinical setting, to which students will ultimately be exposed.

Acknowledgements. The authors would like to thank the students who agreed to participate in this study.

References 1. Haider E. Clinical simulation: A better way of learning? Nurs Manag (Harrow) 2009;16(5):22-23.

2. Gaba DM.The future vision of simulation in health care. Quality and Safety in Health Care 2007;12(1):2-10.

3. Langlois J, Thach S. Teaching and learning styles in the clinical setting. Family Medicine 2001;33(5):344-346.

4. Meyer S, van Niekerk S. Nurse Educator in Practice. Cape Town: Juta, 2008.

5. Larkin BG, Burton FJ. Evaluating a case study using Bloom’s Taxonomy of Education. AORN J 2008;88(3):390402. [http://dx.doi.org/10.1016/j.aorn.2008.04.020] 6. Harton BB. Clinical staff development: Planning and teaching for desired outcomes. J Nurses Staff Dev 2007;23(6):260-268.

7. Ming Su W, Osisek PJ, Starnes B. Applying the revised Bloom’s Taxonomy to a medical-surgical nursing lesson.

Nurse Educ 2004;29(3):116-120.

8. Brannan JD, White A, Bezanson JL. Simulator effects on cognitive skills and confidence levels. J Nurs Educ 2008;47(11):495-500.

9. Lamb D. Could simulated emergency procedures practices in a static environment improve the clinical performance of a Critical Air Support Team (CCAST)? A literature review. Intensive and Critical Care Nursing 2007;23:33-42.

10. Haigh J. Using simulation to prepare students for interprofessional work in the community. J Nurs Educ 2007;7(2):95-102.

11. Stefanski RR, Rossler KL. Preparing the novice critical care nurse: A community-wide collaboration using the benefits of simulation. J Contin Educ Nurs 2009;40(10):443-451. [http://dx.doi.org/10.3928/00220124-20090923-03] 12. Department of Health. The Primary Health Care Package for South Africa – a Set of Norms and Standards. Pretoria: Government Printer, 2000. http://www.doh.gov.za/docs/policy/norms/full-norms.html (accessed 2 May 2011).

13. Guba EG, Lincoln YS. Fourth Generation Evaluation. Beverly Hills: Sage, 1985.

14. Tesch R. Qualitative Research: Analysis Types and Software Tools. Bristol: Farmer, 1985.

15. Ward-Smith P. The effect of simulation learning as a quality initiative. Urol Nurs 2008;28(6):471-473.

16. Clark DR. Big Dog & Little Dog’s Performance Juxtaposition: Bloom’s Taxonomy of Learning Domains, 2010. http://www.nwlink.com/~donclark/hrd/bloom.html (accessed 2 May 2011).

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Research Changing students’ moral reasoning ability – is it at all possible?

N Nortjé,1 DPhil; K G F Esterhuyse,2 PhD 1

Department of Dietetics, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa

2

Department of Psychology, Faculty of the Humanities, University of the Free State, Bloemfontein, South Africa

Corresponding author: N Nortjé (nnortje@uwc.ac.za)

Background. Ethics training at tertiary level is important to facilitate an understanding of patient dignity and respect. Traditionally, ethics has been taught in the form of didactic lectures; however, the authors are of the opinion that practical applications are more useful.

Objective. To measure students’ moral reasoning frameworks before and after an intensive course in medical ethics.

Methods. The study cohort was given a pre- and post-test of the moral behaviour scale (MBS). The t-test for matched scores was performed to determine the presence of significant differences between the mean pre- and post-test scores for the 5 scales of the MBS. Results. The study showed that there was a change in the students’ moral behaviour when a specific course structure was evaluated.

Conclusion. A combination of didactic and Socratic methodology of training had some effect on the moral reasoning ability of healthcare students.

Afr J Health Professions Educ 2015;7(2):180-182. DOI:10.7196/AJHPE.385

An assumption that higher moral reasoning is a desirable quality for healthcare providers is supported by research that shows a correlation between moral reasoning ability and good clinical performance.[1] However, moral reasoning (ability to distinguish between right and wrong and good and bad) can only begin, as a cognitive process, once a problem has been identified.[2] This is disconcerting, as a considerable body of evidence indicates that people have little, if any, insight into what constitutes a moral problem and the processes underlying their judgements (mainly evaluations or estimates) and decisions (an intention to pursue a particular course of action), causing their moral behaviour to be based essentially on rationalisation.[3,4] According to Kohlberg’s cognitive moral development theory, an individual must first become aware of an ethical issue before ethical judgement processes are likely to be triggered.[5] Kohlberg and Blatt worked on a theory[6] in which they argue that individuals can only move to higher levels of moral reasoning by reorganising their thinking after they have had the opportunity to grapple independently and actively with moral issues or dilemmas one stage above their current moral development.

Traditionally, ethics has been taught in the form of didactic lectures in which much information has been given to students, who had to reproduce the facts.

The author concurs with Rest[7] that this kind of methodology is counterproductive in isolation as a singular teaching technique where only summative assessment is done. Rest[7] argues that Socratic classroom discussions (smallgroup discussions (usually 5 - 15 participants) about universal questions) held over several months can produce changes (understanding issues as having a moral base) which, although small, are significantly greater than those found in control groups that have not had this experience. The aim of this study was therefore to conduct a pilot study in a South African (SA) study to test the assertions of Rest[7] and investigate whether a combination of didactic and Socratic teaching approaches could influence a group of students’ moral reasoning abilities. The aim is furthermore to use the knowledge gained from this study and to conceptualise a next study where suggestions could be tested, such as the integration of moral frameworks and reasoning activities into the general curriculum rather than it being a separate module.

A 1-week course was presented to include Beauchamp and Childress’ four basic principles (autonomy, beneficence, non-maleficence and justice) as

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well as assisting participants’ growing awareness of one another’s viewpoints on values and also their consciousness of their own personal values. In addition to this information about the legal requirements, the formation of psychological structure in moral reasoning and the implication of one’s actions were also provided to give the students a holistic picture of the effect of decision-making. Applying the acquired knowledge and skills through a final grand finale group case study presentation, the students were challenged to overcome their own prejudices and give their objective analysis of a case within their field of study by following the steps of an ethical reasoning.

The duration of the intensive course was 1 week, with 8 hours contact per day with a facilitator. The format of the course was both didactic (moral instruction) and Socratic (answering questions with questions, where participants were challenged to form their own insights and solutions).

The formal tuition (as described above) was supported by multimedia presentations (video-clips and podcasts) of influential case studies, ethical dilemmas and opinion analysis found in the ethical literature. Group work, with an average of 5 - 6 members per group, focused on Socratic dialogue and developed students’ reasoning abilities. Each group had individual contact time with the facilitator during the day, when everyone had to give his/her opinion about an ethical dilemma to challenge ideas and internalise new constructs. The objective of the research was therefore to measure students’ moral reasoning frameworks before and after the intensive course in medical ethics to address the research question.

Methods

Participants and instruments

The authors wanted to ascertain whether a 40-hour, week-long course of basic ethics training would influence the moral behaviour, reasoning and judgement of a group of final-year dietetic university students, regardless of whether the influence was only temporary. The aim was to prove that it is possible, and to suggest incorporation over a longer period of time (curriculum integration). To test the research question, 38 fourth-year dietetics students at a tertiary institution in SA were asked to participate voluntarily in the study. The course was part of their degree programme. No student was coerced into completing the questionnaires and all 38 students participated in completing the survey anonymously. Ethical clearance

Research was obtained from the Ethics Committee of the University of the Free State, Bloemfontein (ECUFS No. 139/2011) to conduct the study.

The students were asked to complete a biogra­ phical questionnaire. Table 1 indicates their gender.

Although females usually score higher than males in moral behaviour and judgement tests [8] (possibly because of their genderspecific socialisation processes [9]), this variable was not included in the study as the majority of the group was female and only 3 were male.

The students were also asked to complete Crissman’s moral behaviour scale (MBS) (adapted

by Rettig and Pasamanickas[10]) before class time, and after completion of the course (outside class time). The scale consists of examples of different behaviours, grouped into 5 categories as clustered, and described by Gorsuch and Smith.[8] The students were asked to judge all 50 items as either moral or immoral. The categories are: 1. Misrepresentation, e.g. a student who has been allowed to grade his own paper and reports higher marks than achieved.

2. Irreligious hedonism, e.g. falsifying a child’s age to secure a reduced fare.

3. Sexual misbehaviour, e.g. a man deserting a girl whom he impregnated without taking responsibility.

4. Non-philanthropic behaviour, e.g. not giving to charity when able to.

5. Non-conservative marriage pattern, e.g. seeking divorce because of incompatibility when both parties agree to separate.

The scale values range between 1 (‘I strongly agree’) and 10 (‘I strongly disagree’). Therefore, a higher average score would indicate that the person disagreed more with the specific action/subscale, i.e. a higher score on the mis­ representation subscale would indicate that it is less acceptable. Averages per category were calculated and converted to a score out of 100 to simplify statistical analysis.

Distribution, %

Female

92

Male

8

Discussion

The study did show that there was a change in the students’ moral behaviour and that the training had some effect. The students started to view the different scenarios in a less rule-orientated fashion (which is synonymous with religiosity) and started to move from Kohlberg’s stage 4 (conventional level) to a more principled stage 5, where the individual determines what is right and wrong more autonomously by looking to universally held principles of justice and rights. Thereby, the students became aware of and started to identify moral issues. Applying an analytical framework (four-quadrant analysis of ethical problems), the students were forced to think more widely than their basic assumptions and incorporate more detail into their moral judgement-making.

This stimulated more right-hemisphere thinking, which explains the downward pattern in all the post-test scores of the MBS values.

Although the changes in the average scores of the post-test are not as large as anticipated, the fact that the course was run over a single week must be taken into consideration. A limitation of the 40-hour programme is that moral development does not take place or change necessarily over a period of a week. However, the aim of the study was not to indicate total moral reasoning change, but rather to illustrate that in the SA student population such training can influence students’ moral reasoning abilities and that this needs to be explored and extrapolated into a greater part of the curricula. Therefore, a programme in ethical training should be structured over a longer period, where the students have more time to engage in a Socratic dialogue, be challenged to move to a

Analysis of data

To determine the presence of significant differ­ ences between the mean pre- and post-test scores for the 5 scales of the MBS, the t-test for matched scores[11] was performed. This test does not determine whether there is a significant difference in the means of two groups, but rather investigates whether the mean difference equals 0. Consequently, the mean scores ( X ), standard deviations (s), mean difference scores (D) and standard error of the mean (SG) for the different dependent variables are reported. To determine the difference scores, the post-scores were subtracted from the prescores.

Results

The descriptive statistics (averages and standard deviations) for the total research group affecting the 5 subscales of the MBS are given in Table 2.

As shown in Table 2, only 2 of the 5 subscales have significant t-values (misrepresentation and sexual misbehaviour), which means that these are the only 2 subscales where a change in the moral reasoning of the total group has taken place.

The average post-score for misrepresentation is significantly higher than its average prescore, while sexual misbehaviour is the opposite, i.e. the average post-score is significantly less than the average prescore. The last column indicates, by means of the Cohen d-value, that these differences have medium effect sizes, where effect size means the relation the average participant in

Table 1. Distribution of total group with regard to gender Variable

the study has to the average control group (those not included in the study). This is an indication that the results are of practical significance and should be noted as areas where change has taken place.

Table 2. Mean scores (x ), standard deviations (s), mean difference scores (D) and standard error of the mean (SG) for the matched difference scores Prescore

Difference score

s

D

SG

t-value

Two-sided p-value

d

Misrepresentation

60.20

8.22

62.88

8.25

−2.68

1.10

−2.434*

0.023

0.48

Irreligious hedonism

13.80

4.83

15.00

5.13

1.20

1.13

1.062

0.299

-

Sexual misbehaviour

25.88

4.39

23.56

5.13

2.32

1.05

2.216*

0.036

0.44

Non-philanthropic behaviour

17.28

5.21

16.40

6.52

0.88

1.40

0.627

0.537

Non-conservative marriage pattern

4.24

3.33

4.16

2.85

0.08

0.78

0.103

0.919

Dependent variable

X

s

Post-score X

*p ≤0.05

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Research cognitive moral stage higher than the present, and have a chance to internalise these opinions and changes.

It would be beneficial to the discipline of ethics training to use the data gathered in this pilot study and do a similar study on a course which runs over an entire degree programme (these currently do not exist in SA) to extrapolate the benefit, and then to follow the graduates in a longitudinal study to see whether they genuinely internalised the principles and were able to apply them in specific situations in their professional conduct.

References 1. Sheenan TJ, Husted S, Candee D, et al. Moral judgement as a predictor of clinical performance. Evaluating Health Professionals 1980;3:394-404.

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2. Green B, Miller PD, Routh CP. Teaching ethics in psychiatry: A one-day workshop for clinical students. J Med Ethics 1995;21:234-238.

3. Hardman D. Judgment and Decision Making – Psychological Perspectives. Chichester, UK: John Wiley, 2009.

4. Nisbett RE, Wilson TD. Telling more than we can know: Verbal reports on mental processes. Psychol Rev 1997;84(3):231-259.

5. Treviño LT, Weaver G, Reynolds SJ. Behavioral ethics in organisations: A Review. J Manage 2006;32:951-990. [http://dx.doi.org/10.1177/0149206306294258] 6. Crain WC. Theories of Development: Concepts and Applications. 6th ed. New York, USA: Prentice-Hall, 2010.

7. Rest JR. Morality. In: Mussen PH, ed. Handbook of Child Psychology. 4th ed. New York, USA: John Wiley, 1983.

8. Gorsuch RL, Smith RA. Changes in college students’ evaluations of moral behaviour: 1969 versus 1939, 1949, and 1958. Journal of Personality and Social Psychology 1972;24(3):381-391.

9. Eisenberg N, Fabes R, Shea C. Gender differences in empathy and prosocial moral reasoning: Empirical investigations. In: Brabeck MM, ed. Who Cares? Theory, Research, and Educational Implications of the Ethics of Care. New York, USA: Praefer, 1989.

10. Braithwaite VA, Scott WA. Values. In: Robinson JP, Shaver PR, Wrightman LS, eds. Measures of Personality and Social Psychological Attitudes, vol. 1. San Diego, USA: Academic Press, 1991.

11. Howell DC. Statistical Methods for Psychology, 6th ed. Belmont, USA: Thomson Higher Education, 2007.

Research Experiences of medical and pharmacy students’ learning in a shared environment: A qualitative study D Johnston,1 BPharm, MPharm; P A McInerney,2 PhD; O Fadahun,2 MSc (Med), MB BS; L P Green-Thompson,2 MMed (Anaesthesia), MB BCh; S Moch,1 MEd, MSc (Med), BSc (Hons), BPharm; P Goven Shiba,1 MB BCh, BSc (Hons) Pharmacology; A Magida,2 BSocSci (Hons) 1

Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

2

Centre for Health Science Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: D Johnston (deanne.johnston@wits.ac.za)

Background. Patient care is significantly affected by doctors and pharmacists, who have specialised knowledge and skills. In establishing an interprofessional undergraduate learning environment, medical and pharmacy students have the opportunity to start working in a collaborative manner early on in their careers.

Objectives. To implement combined clinical visits, where medical and pharmacy students jointly encounter patients, and to establish the students’ perceptions of working in an interprofessional team.

Methods. Final-year pharmacy students together with third-year medical students at the University of the Witwatersrand, Johannesburg, South Africa were invited to participate in weekly joint patient encounters at a central academic hospital from May to July 2012. Students assessed patient records and participated in the patient consultation, guided by the supervising doctor. Participants from each discipline were invited to attend a disciplinespecific focus group discussion, where they shared their perceptions and experiences. The discussions were audio-taped and transcribed verbatim.

Content analysis was used to analyse the transcriptions. Ethics approval was obtained from the Human Research Ethics Committee of the University.

Results. Four themes were identified: the meeting of professions; shared teaching and learning; reciprocity in teaching and learning; and valuing the experience. It is evident that there was a change in students’ attitudes, and they developed mutual respect and a better understanding of their professional role and that of their peers. They also reported positive experiences in learning from and with one another.

Conclusion. This study focused on eliciting students’ perceptions and attitudes towards interprofessional teaching and learning. The positive responses to the experiences suggest that further learning opportunities should be created with students from another discipline.

Afr J Health Professions Educ 2015;7(2):183-186. DOI:10.7196/AJHPE.394

Interprofessional education is central to the development of collaborative practice among healthcare professionals.[1] It ‘occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ and includes the training of undergraduate students from different disciplines working together in a learning environment.[2] Collaborative learning between healthcare professionals improves the efficiency of the healthcare system through shared integration of skills and knowledge. It also leads to the development of mutual respect and identifies new roles and responsibilities of team members.[3] The promotion of an interprofessional undergraduate learning environment offers health science students an opportunity to work in a collaborative manner early on in their careers. This co-operative setting may prevent stereotyped and negative attitudes that students may develop towards other professions.[4] Doctors and pharmacists have specialised knowledge and skills, with the common goal of improving patient care. Relationships between these two professions can be strengthened by means of collaboration.[5] Studies involving interprofessional education of medical and pharmacy students are limited; however, available outcomes indicate that there are benefits to joint learning opportunities, e.g. learning to work in a team.[6-8] The University of the Witwatersrand’s Faculty of Health Sciences, Johannesburg, South Africa (SA) offers undergraduate degree programmes in six health professions. This provided an opportunity to instigate interprofessional encounters of patient care between pharmacy and medical students to establish students’ perceptions of working together.

Methods

Organisation of the patient encounter

The study took place at one of the large tertiary teaching hospitals associated with the University. In the current system, the medical students attend weekly clinical practice days while the pharmacy students are assigned to the hospital dispensary. Medical students were expected to elicit a patient history and conduct an examination before presenting their findings to the attending doctor during a bedside tutorial. The pharmacy students, however, during their time in the dispensary, participated in stock procurement, extemporaneous compounding, dispensing of medication and patient counselling.

For the purpose of this study, all the participating students were registered at the University of the Witwatersrand and the supervising staff members were employed jointly by the Faculty of Health Sciences and the Department of Health. Fifteen groups were formed, each consisting of a final-year pharmacy student and 2 third-year medical students, to learn clinical skills, history taking and examination as well as discussing the pharmacological management of the patient. Rather than going to the dispensary, the pharmacy students attended medical student clinic rounds and participated in the patient clerking process and ensuing tutorial.

The joint clinical groups participated in weekly visits to the wards between May and July 2012. These groups were assigned to wards as per the normal rotation of the medical students involved. Working as a group, the students were expected to assess patient records and participate in patient consultation, guided by the supervising doctor. Because of the opportunistic

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Research nature of the clinical learning environment, learning outcomes were not specified for each week.

Focus groups

Students who participated in the encounter were invited to attend disciplinespecific focus group discussions, where they could share their perceptions and experiences. Informed consent was obtained for study participation and audio-recording. The discussions were conducted in a room where privacy could be ensured and the 2 groups were asked the same primary questions (Table 1) by the interviewers who probed further, depending on the ideas that emerged. The audio-recordings were transcribed verbatim and checked by the researchers for correctness. Tesch’s 8 steps were used to guide the data analysis process[9] and common themes were identified.

Table 1. Primary questions asked in each of the discipline-specific focus groups 1

From your perspective, describe the experience of multidisciplinary learning

2

What were the benefits of the encounter?

3

What were the disadvantages or problems with this kind of learning?

4

Do you feel competent in your professional role to participate in the multidisciplinary encounter?

Results

Fourteen pharmacy students and 13 medical students participated in each discussion, respectively. There were male and female participants in both groups. The size of the groups did not appear to adversely influence participation in the discussion. Four themes emerged from the data, i.e. the meeting of professions; shared teaching and learning; reciprocity in teaching and learning; and valuing the experience.

The meeting of professions

This theme was characterised by descriptions of learning to evaluate other professions and understand their contribution to healthcare. This appreciation of others resulted in a changed perception of roles. One pharmacy student stated ‘It’s like the professions almost don’t meet’, describing the interaction between the pharmacy and medical student before the interprofessional encounter. A medical student intimated that there is a perception that the hospital environment was more their ‘domain’ than that of the pharmacy students. A pharmacy student stated that they felt ‘like parasites to them [medical students]; like they are going [on] with their normal routine and we are just on the side’. The pharmacy students relayed comments made by medical students that ‘[a] pharmacist should become doctors’ secretaries; it’s convenient to have them around’. When the medical students described their initial relationship they indicated that the pharmacy students at first seemed ‘shy’ and that they sensed the pharmacy students may have felt inferior to them. Furthermore, a medical student mentioned that ‘medical students sometimes almost tend to give off more superior attitudes’. However, as time progressed, pharmacy students commented that ‘very good relationships’ were formed with the medical students and that ‘mutual respect was a very very important aspect that came to light’.

Learning professional roles was discussed in a range of thoughts and ideas. Gaining understanding of each other’s roles led to a changed perception and was valued: ‘I enjoyed the fact that we gained respect for one

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another.’ Pharmacy students identified their role in the interprofessional encounters as they described two occasions when they had identified an anomaly with the patient’s medication and brought it to the attention of the attending doctor. Furthermore, a pharmacy student found an opportunity to counsel a patient on the correct usage of an asthma pump.

Gaining understanding of each other’s curricula contributed to valuing the other profession – a participating medical student stated: ‘[it showed] me just like how much they are learning as pharmacists. Like they were telling us what they actually study in their degree and you know it just made me realise just how much [more] they know, than I thought.’ The medical students thought that it would be a good idea to have learning opportunities with other professionals, such as physiotherapists, occupational therapists and nursing students.

Taking the shared learning into the postgraduate area, one of the medical students stated that ‘maybe interns could benefit perhaps from a roaming pharmacist, because they have all the pharmacology knowledge and as interns you’re still learning so much ... I don’t know cos I’m not there but I think it could be quite useful to have a pharmacist who could come into [the] wards and help you with the prescribing.’

Shared teaching and learning

There were mixed views in both focus groups with regard to the level of shared learning and teaching. The most commonly expressed view was that the teaching and learning experiences were shared, and that each group of students contributed to and benefited from the exercise.

A medical student’s perspective was that ‘[the pharmacy students] were always willing to learn and always go to the tuts [tutorials] with us, they even wanted to [do] clinical skills with [us] and asked us things.

So we were always teaching them and they were teaching us back.’ This perspective was endorsed by some of the pharmacy students, with one stating that ‘I learnt a lot about taking a proper patient history from my colleague who was a medic student, and she learnt from me when I was going through the medication with her, what it’s for and why shouldn’t you give it to this patient’.

A minority of students, however, were at variance with this interpretation.

The medical students expressed the view that the pharmacy students imparted their knowledge about drugs, but gained little in return. These views were expressed as follows: ‘No, I don’t think I taught them anything or we did. I think they taught us all the drugs.’ And another confirmed that ‘they never once asked us “what is this disease?’’, never once. So for me it was more of a case of they were teaching us, I don’t know what they gained from it.’ This was not the view of all the medical students. One of the pharmacy students expressed her disappointment at the asymmetry of her learning experience compared with that of the medical students, saying ‘I couldn’t wait meeting the medical students but personally I found that they … they learned more. I feel I could have benefited more.’

While many of the pharmacy students were enthusiastic about the opportunities that they were afforded to learn clinical skills, their main dissatisfaction arose from the perception that the focus of the hospital day at third-year level for the medical students was in developing sufficient clinical acumen to be able to correctly diagnose a patient’s ailment. The pharmacy students would have preferred an emphasis on therapeutic management.

One of the students felt that ‘the clinical aspect of it was much more dominant and [the] pharmacological side was much less covered’ (referring to the teaching input).

Research Reciprocity in teaching and learning

Students acknowledged that the process of teaching assisted them in their own development of knowledge and skills. A medical student stated: ‘I found that the most helpful aspect of this experience for me, was the fact that we were kind of instructing or teaching as it were the pharmacology students in our clinical things that we were doing, and so that obviously helps you to learn quite a lot when you’re instructing someone else. That was probably the most beneficial part that I found.’

The medical students observed that the pharmacy students contributed drug information, specifically with regard to generic drug names, trade names, recognition of adverse effects and sourcing of drug information. They also improved the speed at which the preparation sessions occurred, as they provided a faster source of information than the medical students, who had to refer back to their notes. One medical student reflected that ‘I think the best learning experience for both pharmacy students and medical students was the time we went through the patient files – that whole process was sped up so much. We would have trouble with the drugs, specifically with trade names and they help there by far with the whole experience in those settings.’

The medical students felt that they were able to teach clinical skills to the pharmacy students and explain the background pathology and microbiology to them to assist in developing their understanding of the patients’ problems. This reciprocal teaching was expressed as follows: ‘For me it was pretty helpful because my pharmacy student had an assignment of taking patient history and examination and I had an OSCE coming up, so I was kind of practising and teaching him and we were helping each other.’

Valuing the experience

Students ascribed value to the experience of peer learning as they felt able to question and argue with their student colleagues in constructing their own understanding. They thought that explanations were less complicated and the whole learning situation was simplified compared with when they were taught about drug therapy by a staff member who was hierarchically superior. This ability to construct knowledge through discussion was described as follows: ‘It’s nice hearing all of this information from someone who is your peer as well, it’s easier too, I don’t know if I’m not sure or disagree, I find it easier to sort of argue with them and then let’s just say come to a conclusion, it’s easier to do that with a peer than someone who is considered your superior.’ Another medical student described this benefit, saying that ‘clinicians are really advanced. They just say this is how it works and that is what we expect.’

While the medical students valued the drug information provided by the pharmacy students, they also valued the resources that the pharmacy group provided: ‘My pharmacology student had a SAMF [South African Medicines Formulary] – so that was probably the most useful part.’

The long-term value of the experience extended beyond the allocated time period to enrich other learning. This was expressed by a medical student who noted that ‘it was nice to have someone to talk to throughout the block, not necessarily just on hospital days. I had formed quite a good relationship with my student and I was able to ask her questions I had regarding pharmacology we were doing.’

Discussion

This study was the first of its kind at the University of the Witwatersrand, involving undergraduate medical and pharmacy students participating in joint patient encounters. These two professional disciplines traditionally

had had little or no student interaction at an undergraduate level. The intervention was largely unstructured, as outcomes were not explicit other than participation in groups in the clinical setting. This may warrant further attention in future efforts in interprofessional learning. The four themes demonstrate positive results. It is evident that there was a change in attitude of the students, the development of mutual respect, a better understanding of their professional role and that of their peers, and positive learning experiences from and with one another. Other studies involving interprofessional undergraduate pharmacy and medical students support our findings.[6,8] Both groups of students noted attitudes related to superiority and hierarchy. For the pharmacy students this was compounded by the fact that they joined the medical students in their ‘domain’. Gilbert[10] notes that competition exists between medical practitioners and pharmacists and suggests that each profession appears to need to protect their individual professional rights to diagnose, prescribe and dispense. This may explain the antagonistic relationships that often exist between these two professional groups, which may, in turn, filter down to the students.

However, the students described improved understanding of the other profession, and relationships and friendships formed over the course of the intervention. Similarly, O’Neill and Wyness[8] found that students’ participation in teams led to relationships being formed among students, deepening their understanding of the professions. Interprofessional activities could assist to ‘break down unnecessary barriers’ between doctors and pharmacists,[6] as seen in the change of the students’ attitude to one another in our study.

Mutual respect was formed between the two groups. The pharmacy students described the development of respect over time between them and the medical students, and they felt that the medical students respected them more when they could see the contribution the pharmacy students could make to their learning. The medical students concurred with this perception when they expressed surprise at the extensive content of the pharmacy curriculum. This development of mutual respect is consistent with one of the principles of interprofessional education described by Parsell and Bligh,[11] i.e. ‘respects the integrity and contribution of others’.

Participants in this study noted the varying interests between the two student groups, i.e. the medical students were interested in the examination and diagnosis of the patient’s condition, while the pharmacy students were focused on medication. These interests are consistent with how students view their roles in their professions. This concurs with the findings described by Greene et al.,[6] who found that medical students were more comfortable with interviewing patients and pharmacy students with drug therapy. The ability to share and gain knowledge and skills in the peer teaching that occurred was clearly described. The medical students found particular value in the pharmacy students’ knowledge of the medications prescribed and therefore viewed the pharmacy students as a useful resource.

However, fewer pharmacy students spoke about learning from the medical students with regard to taking a patient’s history and learning clinical skills.

Hall and Weaver[12] note that there is a need for ‘overlapping competencies and share[d] responsibilities’ for interdisciplinary team collaborations to take place. This may explain the asymmetry in learning expressed by some of the pharmacy students, who had anticipated that they would learn more from the medical students.

Barr et al.[13] describe five levels of educational outcomes that may be identified in interprofessional learning (Table 2).

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Research

Table 2. Modified levels of educational outcomes that result from interprofessional education[13] Level 1: Reaction Level 2a: Modification of perceptions and attitudes Level 2b: Acquisition of knowledge and skills Level 3: Behavioural change Level 4: Change in organisational practice Level 5: Benefits to patients/clients

that students valued this shared experience, which generated a better understanding of each other’s profession and facilitated peer teaching and learning. It has been suggested that to measure effectiveness, students’ attitudes towards interdisciplinary education should be assessed on entry into the programme, after the clinical component, on completion of the course, and when the graduate is practising as a professional.[15] Future studies should consider outcomes concerning ‘changes in behaviour’ relating to professional practice, ‘change in organisational practice’ and ‘benefits to patients/clients’.[13] References

The findings of our study align with levels 1 and 2 of the outcomes (Table 2). The interprofessional learning experience that we implemented generated a reaction from students, modifying their perceptions and attitudes. Both groups reported to have learnt through the shared experience.

The study was initiated to document a shared learning experience between medical and pharmacy students to incorporate interprofessional clinical training in the undergraduate curricula of the two groups. However, several limitations constrain such generalisation. Compared with the total class sizes from both student groups, only a small number participated in the learning opportunity. Furthermore, as participation in this study was voluntary, students’ contribution and performance were not quantitatively measured through assessment. Without placing academic value on participation, students might not place value on the knowledge and skills acquired.[14] Difficulties were experienced in communicating with the supervising doctors; this needs to be addressed in future studies.

Conclusion

Our study focused on eliciting attitudes and opinions of students to learning through exposure in this interprofessional encounter. We found

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1. World Health Organization Study Group on Interprofessional Education and Collaborative Practice. Framework for action on interprofessional education and collaborative practice. 2010. http://whqlibdoc.who.int/hq/2010/ WHO_HRH_HPN_10.3_eng.pdf (accessed 6 December 2013).

2. Centre for the Advancement of Interprofessional Education. Interprofessional education. 2013. http://caipe.org. uk/about-us/defining-ipe/ (accessed 6 December 2013).

3. World Health Organization. Learning together to work together for health. 1988. http://whqlibdoc.who.int/trs/ WHO_TRS_769.pdf (accessed 6 December 2013).

4. Parsell G, Spalding R, Bligh J. Shared goals, shared learning: Evaluation of multiprofessional course for undergraduate students. Med Educ 1998;32:304-311. [http://dx.doi.org/10.1046/j.1365-2923.1998.00213.x] 5. McDonough RP, Doucette WR. Developing collaborative working relationships between pharmacists and physicians. J Am Pharm Assoc (Wash) 2001;41:682-692.

6. Greene RJ, Cavell GF, Jackson SHD. Interprofessional clinical education of medical and pharmacy students. Med Educ 1996;30:129-133. [http://dx.doi.org/10.1111/j.1365-2923.1996.tb00730.x] 7. Horsburgh M, Lamdin R, Williamson E. Multiprofessional learning: The attitudes of medical, nursing and pharmacy students to shared learning. Med Educ 2001;34:876-883. [http://dx.doi.org/10.1046/j.1365-2923.2001.00959.x] 8. O’Neill BJ, Wyness MA. Student voices on an interprofessional course. Med Teach 2005;27:433-438. [http:// dx.doi.org/10.1080/01421590500086680] 9. Cresswell JW. Research Design: Quantitative, Qualitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage, 2003.

10. Gilbert L. To diagnose, prescribe and dispense: Whose right is it? The ongoing struggle between pharmacy and medicine in South Africa. Current Sociology 2001;49:97-118. [http://dx.doi.org/10.1177/0011392101049003007] 11. Parsell G, Bligh J. Interprofessional learning. Postgrad Med J 1998;74:89-95. [http://dx.doi.org/10.1136/pgmj.74.868.89] 12. Hall P, Weaver L. Interdisciplinary education and teamwork: A long and winding road. Med Educ 2001;35:867875. [http://dx.doi.org/10.1046/j.1365-2923.2001.00919.x] 13. Barr H, Freeth D, Hammick M, Koppel I, Reeves S. Evaluations of interprofessional education. A United Kingdom review for health and social care. The United Kingdom Centre for the Advancement of Interprofessional Education with the British Educational Research Association. 2000. http://caipe.org.uk/silo/files/evaluations-ofinterprofessional-education.pdf (accessed 28 November 2013).

14. Parsell G, Bligh J. Educational principles underpinning successful shared learning. Med Teach 1998;20:522-529. [http://dx.doi.org/10.1080/01421599880229] 15. Gilbert JHV. Interprofessional education for collaborative, patient-centred practice. Nursing Leadership 2005;18:32-38.

Research Ethical dilemmas experienced by occupational therapy students – the reality N Nortjé,1 DPhil; J de Jongh,2 PhD 1

Department of Dietetics, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa

2

Department of Occupational Therapy, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa

Corresponding author: N Nortjé (nnortje@uwc.ac.za)

Background. Ethics training strives to facilitate critical thinking, objective analysis and clinical reasoning skills to equip students with the ability to make an impartial and unbiased decision in different contexts and diverse client populations. This enhances students’ learning experiences.

Occupational therapy (OT) students are expected to work in a variety of contexts. They experience many sources of conflict in their fieldwork practice on a daily basis, while at the same time upholding professional values, responsibilities and duties.

Objectives. To determine the issues that students face in their fieldwork practice and address these in an ethical manner.

Methods. Qualitative research was done among fourth-year OT students by means of an open-ended questionnaire.

Results. Three major themes relevant to ethical issues were identified: professional-student relationship; professional boundaries; and disclosure of information and keeping information confidential.

Conclusion. The salient themes identified reflect the primary ethical tensions in the international literature from the UK and Canada, but little evidence has been reported from South Africa. Taking cognizance of this, those who are involved in the training of healthcare professionals should incorporate the identified issues in the class discussions. For many students their fieldwork practice may be their first experience with some of the aforementioned issues.

Alluding to these in a safe environment (class situation) and equipping the students with a framework of analysis are very important.

Afr J Health Professions Educ 2015;7(2):187-189. DOI:10.7196/AJHPE.396

Ethics in healthcare is an important determinant of the professional out­ comes for occupational therapists' daily professional practice.[1] The Health Professions Council of South Africa (HPCSA) places great emphasis on ethical behaviour towards clients and expects registered professionals to act accordingly.[2] Occupational therapy (OT) students are expected to work in a variety of contexts and they experience many sources of conflict in their fieldwork practice on a daily basis, while at the same time upholding professional values, responsibilities and duties. This conflict results in ethical dilemmas, such as when an individual faces two or more equally stressful alternatives that are mutually exclusive.[3] According to Pauly et al.,[1] moral conflict is closely associated with the ethical dimensions of practice. In accordance with the Occupational Therapy Professional Board’s Minimum Standards for the Training of Occupational Therapists, the curricula should include ethics as part of the undergraduate training programme.[4] Research indicates that OT students are mostly aware of the correct course of action, but often feel constrained to act in another way as a result of institutional and/or societal rules.[5] Ethics training strives to facilitate critical thinking, objective analysis and clinical reasoning skills to equip students with the ability to make an impartial and unbiased decision in different contexts and diverse client populations, which enhances students’ learning experiences.[6] Ethical training is guided by a consequential framework, where the outcome should guide the behaviour of clinicians, or a rule-based (deontological) approach, where rules (i.e. codes of ethics) should guide the conduct of a professional.

According to the HPCSA’s sub-committee, ethics training should focus on a careful and systematic reflection of the analysis of moral discussions and behaviour in the healthcare environment,[1] which is a hybrid between the aforementioned approaches.

Metz[7] makes an interesting statement by arguing that ‘… [t]oday’s dilemmas make tomorrow’s rules’. As ethics evolves over time, the challenges currently faced by professionals and the decisions they make accordingly, become the standard of future practice. Therefore, it is imperative for healthcare educators to understand the issues students face in their everyday fieldwork practice and equip them to deal with these ethical issues.

Objectives

The objective of this research was to determine the issues that students face in their fieldwork practice and address these in an ethical manner.

Methods

As the aim of the study was to hear the voice of the student, it was decided to use qualitative methodology, where the focus is not on refining any hypothesis, but on a narrative investigation into the field of experience of the research participants. A non-probability sampling technique was used by interviewing a cohort of 30 final-year OT students from a university in South Africa (SA). As this study is exploratory, purposive sampling was employed, where certain individuals with specific experiences were identified.[3] The inclusion criteria were the following: English speaking; OT final-year student; student registration with the HPCSA; registration at a SA university.

Data were collected using an open-ended questionnaire. No individual was coerced into completing the questionnaire and all students were assured that they could leave the study at any time. Anonymity was ensured – no personal identifiers were recorded (i.e. name, surname or student number).

The study protocol received ethics approval.

As the aim of qualitative research is not to make a statistical generalisation to any population beyond the sample surveyed, no control group was

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Research included in the study. The reliability or consistency of the data analysis in qualitative research is an evolving process, and the interpretation thereof can differ vastly.[7] The authenticity of the data is very important, which refers to the concept that a fair, honest and balanced account of social life − from the viewpoint of someone who lives through it daily[8] − has been given.

Qualitative data analysis is generally based on organising the data into categories based on themes and coding the latter to derive salient themes.

This is achieved by organising the data into categories by using themes and concepts. In this study, the participants’ answers were coded using an opencoding technique, where general themes were identified and each answer was coded accordingly. Once the first round of coding was complete, a second round was conducted, i.e. axial coding. During this phase, the researchers organised the themes and coded each into subthemes to ascertain whether or not there were any relationships between subthemes from the initial opencoded themes. Once all subtheme relationships were identified, a final round of coding took place, whereby selective coding was performed and salient themes were identified, together with any subtheme relationships. These, as well as the final salient themes, are presented in the results section.

Results

This section reports on the most significant themes identified after the data were analysed by applying the methodology discussed above. Three major themes relevant to ethical issues were identified and are presented below to give voice to the students and illustrate the meaning.

Professional-student relationship

For many students an ethical dilemma occurs when they are unsure how to approach a situation where they disagree with a qualified OT with regard to an alternative form of therapy they believe is in the best interest of the client. Students often feel that they do not have the authority to approach a senior staff member (or report them in severe cases) and cannot question the behaviour of qualified therapists, as it could possibly cause tension and even impact negatively on their results/reports. One student observed: ‘While doing practical I built up good interpersonal relationships with the staff and clients. However, just before mid-practical evaluation, my supervisor called me in to discuss a complaint that she has received from the clinician at the placement. The clinician asked the supervisor to inform me that I was not behaving in a professional manner (I was too friendly with the clients) and that I needed to tone down my friendliness.

This was discouraging and impacted negatively on my group sessions. I had difficulty to decide whether to be true to myself and behave the way I did initially in order to maintain good interpersonal relationships with the group members and ensure effective intervention or do what the clinician said in order not to be marked down on professional behaviour.’

Professional boundaries

Being in a caring profession, where students frequently are confronted with the vulnerabilities of clients, it is often difficult to distinguish between professional and unprofessional behaviour. Furthermore, because the student often also engages with clients on a personal level, the latter feel they can trust the students and will often share information that could be deemed as outside the scope of practice. This conduct is in itself not commendable, as it contravenes the boundaries of a professional therapeutic relationship.

However, as students are still learning about these boundaries, they are often hesitant to be firm because they are afraid it would impact negatively

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on their relationship, resulting in clients taking advantage of them. The following is an example of such an issue, as highlighted by a student: ‘During fieldwork I was required to build relationships with clients. I was able to build extremely good interpersonal relationships with all my clients however with one of my clients it became uncomfortable. He asked me if I could bring him DVDs to watch as it was boring at the rehabilitation centre.

I did so and we built up a good relationship with each other, however he kept asking me to bring him things such as food. I knew that I needed to draw the line, but was cautious as it would affect our relationship with each other.’

Disclosure of information and keeping information confidential Students are often in despair as they are not sure what to do with confidential information that other members of the multidisciplinary team have shared with them. The following illustrates the issue: ‘During my placement at a school there was one particular teacher that I worked closely with as I saw individual clients from her class as well as ran groups with the learners. Often the teacher would speak about the learners in an inappropriate manner, making fun of them, openly disclosing information or just speaking about them in a negative manner.

It was difficult for me to know what to do.’

Furthermore, the students are uncomfortable with the places where and manner in which the information-sharing happens – often in non-private settings such as hallways or classrooms. Most students are aware of their duty to protect client confidentiality, and often witness how other members of the healthcare professions team show a lack of respect for client confidentiality.

‘As I worked in a multidisciplinary team at a drug rehab centre a nurse (whose consulting rooms were next to my office) was seeing one of the clients and she was scolding her about having a sexually transmitted infection (STI) and that she should not be having sex because she is still a minor. The nurse also accused the client of “sleeping around” and stated that it was the reason why she had the STI. Unfortunately, the nurse did not close the door while she was speaking to the client and almost all of the male clients at the rehabilitation centre, who were coming from a group session with the counsellor, had heard the nurse disclose this client’s illness and because she did not close the door, the male clients were also able to see who the client was – therefore putting her at risk. This made me feel uncomfortable as I was unsure how to handle the situation.’

Discussion

The salient themes identified by this study echo the primary ethical tensions seen in the international literature from the UK and Canada,[9,10] but little evidence has been reported from SA. This discussion adopts a critically reflective position to contemplate the described experiences of students in light of peers from the UK and Canada and to participate in a discussion about the consequences for professional practice, educational reforms, and policy issues. The findings highlight the salient themes of ethical dilemmas that OT students face during fieldwork practice. These ethical issues will be employed to inform a framework that could be used to assist them in their ethical reasoning process. The aim of any framework is to create critical thinking, where nothing should be taken for granted; instead, the practitioner should ask critical questions about conventions, opinions and sentiments and ultimately be aware of incorrect reasoning that could influence the practitioner in accepting positions that are not supported by analytical arguments and evidence.

Research Professional-student relationship

For most of the students conflict arose when there was a difference of opinion that contributed to moral differences. The sensitivity of the students towards the issue could be the result of the ethics training that they received.They consequently know what to expect of the different role players in the therapeutic setting.

Moral differences are often difficult for students to understand as they might not have had exposure per se to similar circumstances to ascertain the correct way to behave in such situations. In an attempt to address this, we draw on the work of Immanuel Kant, who developed the obligation-based theory in which he argues that one should rest one’s moral judgements on reasons that also apply to others who are similarly positioned.[11] Therefore, the ability to make a moral decision should be guided by a combination of practical reasoning (experience) and pure reasoning (not having had any experience). However, the act should be guided by what Kant calls a universal maxim/imperative, which states that one’s behaviour in a situation should be of such a manner that, should it become universally applicable, it would be to the benefit of humanity at large.[12] The focus of deontology is not the end result of an action, but rather whether the action itself is morally acceptable.

Through applying this framework, the students should soon realise that what is good is not always right and what is bad is not always wrong.

Being able to take this metaposition will enable students to deal with issues of conflicting value systems. When students feel that the opinion of their senior is not morally justifiable (applying Kant’s universal maxim) they should report the behaviour, even though the outcome could potentially be negative.

Professional boundaries

Allan[13] defines a boundary as ‘an imaginary line between behaviour that is generally appropriate when a therapist acts in a professional capacity, and behaviour that is not’. Similar to Kant’s assertion that experience is a guiding factor in moral behaviour, the same applies to setting boundaries. As boundary setting is very subjective and influenced by factors such as public morality, professional standards and culture, a feeling of unease will develop with a young practitioner if his/her boundaries have been crossed. The HPCSA’s guidelines assist practitioners in drawing boundaries by advising who should not be treated (i.e. family members, friends, people bringing gifts).

The setting of boundaries assists the young practitioner to conduct therapy professionally, creates safe environments for clients and sets parameters within which services are delivered. The primary concern in establishing and managing boundaries with clients must be in the best interests of the client.

Students should be careful not to disclose too much personal information (e.g. personal cell phone number); self-disclosure should be well considered and the motivation of such disclosure should be well examined.

Another important aspect of drawing boundaries is guided by the clothing a practitioner wears. Research indicates that a person’s clothing may convey a very powerful symbolic message.[14] As a general guiding rule, clothing should be neat but conservative and always take the work environment into account.

Confidentiality

There seem to be inconsistencies in the students’ understanding of privacy and confidentiality. Although the two are very closely linked, there are distinct differences. Privacy refers to the notion of access to others, whereas confidentiality is restricted to information, how it relates to accessing such information and how it is applied.[15]

Confidentiality is not only an ethical principle, as enshrined in the principle of respect of autonomy,[12] but is also addressed by the HPCSA’s Guidelines for Good Practice in the Health Care Professions.[16] Brody[17] argues that confidentiality is central to preserving the human dignity of clients and that patient autonomy (concept of self-rule, where clients are informed) should always be considered. Therefore, it is unethical for members of the healthcare team to discuss clients’ information outside a clinical setting; they should refrain from doing so.

Strengths and limitations

The strengths of this study include the importance and veracity of actual accounts of students’ ethical experiences, the extent to which similar themes occurred among the participants, and the possibilities that the study opens for further research and education.

Limitations of this study include the limited generalisation of the results and the geographical representation of the participants, as the research was conducted only at one institution in SA.

Conclusion and recommendations

This article highlights the complex ethical dynamics that students experienced in fieldwork practice. They were taught some basic ethics, which might have sensitised them to the issues identified above. Taking cognizance of this, those who are involved in the training of healthcare professionals should incorporate the identified issues in class discussions. For many students, their fieldwork practice may be their first experience with many of the abovementioned issues.

Alluding to these in a safe environment (class situation) and equipping the students with a framework of analysis are very important. Once the students have the ability to objectively remove themselves from a specific situation and realise that the focus of the case should not be themselves but rather the patients/ clients and the benefit of the latter, then only will they be able to apply their critical thinking abilities. Formal classroom time should be spent on creating critical thinking abilities, simulating as many situations as possible and alluding to the difference in people’s ethical and moral reasoning abilities, which should be taken into consideration when applying the skills the students are taught.

Furthermore, educators should realise the importance of listening to the voice of the students and learn from the students’ experiences as they inform where there is a need to address certain issues. Collaboratively, this could contribute to the quality of ethics education and services rendered by healthcare professionals.

References 1. Pauly BM, Varcoe C, Storch J. Framing the issues: Moral distress in health care. HEC Forum 2012;24:1-11.

2. Health Professions Council of South Africa (HPCSA). Proposed Core Curriculum on Human Rights, Ethics and Medical Law for Health Care Practitioners. 2006. http://www.hpcsa.co.za/downloads/radiography/core_ curriculum_on_human_rights_ethics_and_medical_law.pdf (accessed 10 February 2014).

3. Nortjé N. Ethical tensions faced by dietetic students during fieldwork. S Afr J Clin Nutr 2014;27(3):128-131.

4. Health Professions Council of South Africa (HPCSA). Professional Board for Occupational Therapists, Medical Orthotics/ Prosthetics and Arts Therapy. Minimum Standards for the Training of Occupational Therapists. Pretoria: HPCSA, 2009.

5. Atwal A, Caldwell K. Ethics, occupational therapy and discharge planning: Four broken principles. Australian Occupational Therapy Journal 2003;50(4):244-251.

6. Diab P, Naidu T, Gaede B, Prose N. Cross-cultural medical education: Using narratives to reflect on experience.

Afr J Health Professions Educ 2013;5(1):42-45. [http://dx.doi.org/10.7196/AJHPE.234] 7. Metz MJ. Some ethical issues related to hearing instrument dispensing. Seminars in Hearing 2000;21(1):63-74.

8. Neuman WL. Basics of Social Research – Qualitative and Quantitative Approaches. 2nd ed. Boston: Pearson, 2007:108-139.

9. Barnitt R. Ethical dilemmas in occupational therapy and physical therapy: A survey of practitioners in the UK NHS. J Med Ethics 1998;24:193-199.

10. Kinsella EA, Park AJ, Appiagyei J, Chang E, Chow D. Through the eyes of students: Ethical tensions in occupational therapy practice. Revue Canadienne D’Ergotherapie 2008;75(3):176-183.

11. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press, 2001.

12. Kant I. Groundwork for the metaphysics of morals. In: Nadelhoffer T, Nahmias E, Nichols S, eds. Moral Psychology – Historical and Contemporary Readings. Chichester, UK: Wiley Blackwell, 2010.

13. Allan A. The Law for Psychotherapists and Councellors. 2nd ed. Somerset West: Inter-Ed Publishers, 2001.

14. Allan A. Law and Ethics in Psychology: An International Perspective. Somerset West: Inter-Ed Publishers, 2008.

15. Sim J. Client confidentiality: Ethical issues in occupational therapy. Br J Occupational Ther 1996;59(2):56-61.

16. Health Professions Council of South Africa (HPCSA). Guidelines for Good Practice in the Health Care Professions – Confidentiality: Protecting and Providing Information (Booklet 10). Pretoria: HPCSA, 2008.

17. Brody H. The physician/patient relationship. In: Vearch RM, ed. Medical Ethics. Boston: Jones and Barlett, 1990.

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Research Promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective I Ndateba,1 MN; F Mtshali,1 PhD; S Z Mthembu,2 PhD 1

School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

2

KwaZulu-Natal College of Nursing, Durban, South Africa

Corresponding author: S Z Mthembu (sindizama@gmail.com)

Background. Community-based education (CBE) serves as a primordial instrument in the implementation of primary healthcare (PHC). Learning experiences in community-based settings provide students with learning opportunities, as they are actively engaged in PHC-associated activities in under-resourced communities. Many nursing schools in higher education integrated and implemented a CBE programme with an end-goal of becoming healthcare practitioners who are responsive to the needs of the community.

Objectives. To establish how PHC philosophy is promoted through a community-based nursing education programme.

Methods. The study was non-experimental and cross-sectional with a quantitative approach and was done at a selected higher education institution in KwaZulu-Natal, South Africa. A total of 118 participants were selected using the non-probability convenience sampling technique. A self-report questionnaire was distributed to the participants; 91 questionnaires were completed and returned – a response rate of 73.3%. Ethical clearance was obtained from the University of KwaZulu-Natal Ethics Review Committee. Participation was voluntary, informed consent was obtained, and other ethical principles were respected. Data were analysed with the Statistical Package for Social Sciences (SPSS). Descriptive and analytical analysis was used to analyse the data.

Results. The participants reported exposure to community-based learning from the first until the fourth year of their study programme. Participants (69.9%) indicated that their learning activities had involved members of the community. The community-based learning projects, which mostly promoted a PHC philosophy, included prevention of illness, injuries and social problems (90.1%), health promotion (89%) and engaging communities in community-based learning activities to promote their self-reliance and self-determination (76.9%).

Conclusion. Findings revealed that the community-based learning experiences of students promoted a PHC philosophy and that under­privileged community settings provided a rich learning environment.

Afr J Health Professions Educ 2015;7(2):190-193. DOI:10.7196/AJHPE.399

The traditional teaching approach has been criticised for not equipping health professionals with the necessary knowledge and skills to work in rural, remote and under-resourced communities.[1,2] The conventional approach focuses on hospital-based, curative-focused teaching, which relies on sophisticated technology. Furthermore, upon graduation, many nurses are reluctant to work in rural, underprivileged areas, where resources are scant and the focus is on healthcare and prevention.[2] This instructional approach hinders the equal distribution of health professionals in South Africa (SA) and therefore the quality of services provided to its citizens. This, in turn, impedes the promotion of primary healthcare (PHC).

The World Health Organization (WHO) defines PHC as ‘essential healthcare based on practical scientifically sound and socially sound acceptable method and technology, universally accessible to all in the community through their full participation; at an affordable cost, and geared toward self-reliance and self-determination’.[3] PHC is therefore an approach to healthcare that promotes the attainment by all people of a level of health that will permit them to live socially and economically productive lives. Healthcare is essential, practical, socially and scientifically sound (evidence based), ethical, access­ ible, equitable, affordable, and accountable to the community. Furthermore, PHC is more than primary medical or curative care or a package of low-cost medical interventions for the poor and marginalised.

To address these challenges, the WHO, International Council of Nurses (ICN) and South African Nursing Council (SANC) recommended the

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implementation of a community-based education (CBE) programme as part of the teaching curriculum in the training of nurses.[2,4-6] CBE refers to learning activities that take place in a particular setting, i.e. the community setting.[7] Students are allocated to different communities (urban, peri-urban and rural or semi-rural) to undertake activities relevant to community health needs and that address community health-related needs. CBE may contribute to solve the inequity in service delivery by producing healthcare professionals who are willing and able to work in underserved areas, particularly rural communities.[8,9] CBE also offers opportunities for students to learn in situations similar to those in which they might work later in their professional lives. It may equip students with transferable core competencies that they would not learn otherwise, such as leadership skills, the ability to work in teams, and the capability to interact with the community.

The South African Department of Education (DoE) and the Council on Higher Education (CHE) endorse the implementation of CBE as a responsive educational method.[10] Furthermore, the Department of Health (DoH) (SA), in the 1997 White Paper on the Transformation of the Health System, highlighted that in order to align nursing education with PHC the curriculum should be based on community needs and linked to PHC.[11] Gumbi and Muller[12] and Mekwa[6] emphasised that the curriculum of health professionals should be linked to PHC. Mekwa[6] states that CBE is a tool to foster PHC, as it affords students the opportunity to learn by providing services to under-resourced communities.

Various higher education institutions for health professionals, including

Research nursing institutions, have responded positively by allowing students to engage in PHC-associated activities.[13] However, little is known about whether this programme promotes the PHC approach. This article presents the findings of a study aimed at exploring whether CBE activities promote PHC.

Methods

Following a quantitative approach and a non-experimental, explorative, descriptive design, a cross-sectional survey was used to explore students’ perspectives of whether CBE promotes PHC. Non-probability convenience sampling was used to invite 118 students to participate in the study. They included second-, third- and fourth-year students who were studying for a Bachelor in Nursing degree at a university-based College of Nursing in KwaZulu-Natal, SA. The students were selected to participate, as they had been exposed to the CBE programme. First-year students were excluded because of the limited exposure to community-based learning at first-year level. Permission to conduct the study was obtained from the University of KwaZulu-Natal Ethics Review Committee. Participation was voluntary and informed consent was obtained from participants after the study had been thoroughly explained to them. Questionnaires were distributed to the participants; 91 were completed and returned – a response rate of 73.3%.

Experts in CBE and PHC at the University of KwaZulu-Natal, and the related literature and studies, facilitated the measurement of validity of the instrument. To test the consistency of the measurements, a pilot study was conducted with 6 participants, who were not included in the final analysis. Descriptive and analytical statistics were used in the data analysis.

Cronbach’s α was 0.851 and a p-value ≤0.5 was considered statistically significant.

Results

Research setting

The selection of clinical training sites in the community is considered an important aspect of CBE for an effective process of knowledge construction.

Students are placed in urban, suburban and informal settlements and semirural communities. The communities around the university are used extensively as a learning environment to give students an opportunity to understand the capacities and initiatives of the communities they serve. Nearby PHC clinics, schools and other community centres are used. These communities all provide rich information with regard to the raw content material and a variety of health problems that could be used as a frame of reference for CBE.

Students are involved in CBE from their first to their fourth year of study and exposed to learning in various community settings, including PHC facilities and other community centres. Their communitylearning activities were carried out in old-age homes (82.4%), crèches (24.4%), general hospitals (94%), PHC clinics (34.4%) and psychiatric settings (36.7%). Participants indicated that their CBE activities promoting PHC had involved community members from different sectors. The study revealed that 69.9% of respondents indicated that their community-learning activities had involved members of the community and 85.7% had participated in the implementation of community projects. It was found that these activities involved school teachers (95.6%), local leaders (91.2%), church leaders (44%), youth leaders (60.4%), community health workers (89%), nurses (87.95) and community members (94.3%).

The student learning experiences also reflect identification of community health problems.

The results of this study showed that 97.8% (n=89) of students had participated in family assessment, while 100% (n=91) had conducted epidemiological studies. Additionally, the findings indicated that 100% (n=91) had carried out community assessment to identify community health needs, and 95.6% (n=81) had validated needs from the community to identify health need priorities.

Eighty-nine per cent of participants had been involved in CBE activities that focused on health promotion, 90.1% on prevention of illness, injuries and social problems, 52.7% on treatment of common illnesses and injuries at home, 45.1% on rehabilitative care, which was associated with learning in an informal settlement, and 76.9% on promoting community self-reliance and self-determination.

The focus of CBE projects can be seen in Table 1.

The study indicated that students were exposed to many aspects of PHC in various learning environments, such as classrooms, communities, PHC facilities and hospitals. In these CBE environments, 71.4% of participants learnt about health education with regard to preventing diseases and promoting health, 52.7% were exposed to learning about oral rehydration for children and 57.1% learnt about breastfeeding. The study also revealed that 62.6% had an opportunity to learn about family planning for males and females and 70.3% learnt about prevention of malnutrition in children.

Furthermore, 58.2% could familiarise themselves with first-aid measures at home, 52.7% with monitoring the growth of children and 60.4% with immunisation of babies.

Table 1. Focus of community-based learning projects Focus of community-based project

Yes, n (%)

No, n (%)

Total, n (%)

Promotion of health (health education on nutrition, sexuality, breastfeeding, environmental health, waste disposal, safe and clean water)

81 (89)

10 (11)

91 (100)

Prevention of illness, injuries and social problems (e.g. immunisations, family planning, health education on prevention of sexually transmitted infections, chronic illnesses (e.g. hypertension) and teenage pregnancy)

82 (90.1)

9 (9.9)

91 (100)

Treatment of common illnesses and injuries at home (e.g. treatment of lice, diarrhoea and vomiting, flu, minor burn injuries)

48 (52.7)

43 (47.3)

91 (100)

Rehabilitative care (e.g. home management of patients with deformities, elderly patients with chronic illnesses, and mentally ill clients in the community)

41 (45.1)

50 (54.9)

91 (100)

Promoting community self-reliance and self-determination (e.g. identifying, accessing and using available resources in the community to address health-related issues)

70 (76.9)

21 (23.1)

91 (100)

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Research The results revealed that CBE had given 70.3% of the participants the opportunity to learn about community involvement in community-based projects, 38.5% had become involved in advocating for vulnerable people and 50.5% learnt about educating the community about waste disposal. The study showed that 56.7% learnt about ways to keep water clean if there is no safe water supply and 51.6% about caring for terminally ill patients at home. Moreover, 57.1% acquired knowledge about women empowerment and 59.3% about collaborating with other sectors to address health issues in the community. The findings indicated that 94.3% of the participants had been involved in fundraising for community projects, while 80.2% had participated in helping the community to take responsibility for their health and mobilising resources for promoting community self-determination.

The community-based learning projects that participants were exposed to were associated with the promotion of health; prevention of illnesses, injuries and social problems; home treatment of common illnesses and injuries; rehabilitative care and community self-reliance and self-determination.

Discussion

CBE is an approach to teaching and learning that exposes students to community nursing from an early stage of the course until their fourth year.

This takes place in a variety of real-world settings, including the community and specialty learning environments as stated by Mthembu and Mtshali.[7] Such early exposure to a community setting aims to familiarise students with PHC principles to equip them with the culture of PHC practice about health promotion and disease prevention.[5,14] The continuity of community learning is crucial as it helps students to maintain a spirit of community practice, while striving to become competent nurses. Ongoing experience of working in PHC settings and providing healthcare services to under-served communities not only reinforces internalisation of health promotion and illness prevention throughout the educational programme, but also makes healthcare services more accessible to the community.

The current study showed that 97.8% (n=89) of students had participated in family assessment, while 100% (n=91) had conducted epidemiological studies.

Additionally, the findings indicated that all students (n=91) had carried out community assessment to identify community health needs, and 95.6% (n=81) had validated needs from the community to identify health need priorities.

These results are congruent with the findings of various other studies[7,15-17] that students who engaged in CBE learnt to identify community healthcare needs and implement health interventions to address health problems. This enables both students and community members to identify real issues in the community and the available resources.[7] As a result of the experience they gain through community studies, students learn to understand how cultural, socioeconomic and political factors are interrelated and how these factors determine the health status of the population.[1,18] This enables them, as PHC practitioners, to implement the necessary measures to affect these determinants of health.

This process of identifying community health problems and validating needs is in line with the PHC philosophy where community members participate in the identification of their needs and resources.[5] Findings showed that the principle of community participation was reflected in this CBE programme, where 70.3% (n=64) of respondents had been exposed to learning about community involvement and 51.6% (n=47) had covered it in the classroom learning environment.

Furthermore, 69.9% of respondents indicated that their communitylearning activities had involved members of the community and 85.7%

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had participated in the implementation of community projects. This embraces the PHC principle that community members should be involved in the planning, implementation, monitoring and evaluation of communitybased projects aimed at addressing their health needs.[19] The findings are also consistent with recommendations from the WHO,[5] which state that community members should be involved in studentsâ&#x20AC;&#x2122; educational experiences, not only to provide support to foster learning, but also to ensure that community needs are satisfied.

The success of CBE depends on community participation in the educational process. The community helps students by identifying health problems in the community, which forms the curriculum content. In return, they benefit from the services provided by students.[7,14] During the learning experience, students and community members jointly plan and implement community-based learning projects, which enhances closeness between both groups, a sense of belonging for students, ownership of the interventions implemented, and their acceptability for the community.[20] This achieves the main objective, i.e. improving the health of the community being served.

The findings indicated that 94.3% of the participants had been involved in fundraising for community projects, while 80.2% had participated in assisting the community to take responsibility for their health. Students were also involved in mobilising resources for promoting community self-determination â&#x20AC;&#x201C; a principle of PHC. The role of PHC practitioners involves helping the community through collaboration, partnerships with other sector teams and advocacy to assume control of their lives.

According to Mtshali,[1] CBE prepares nursing students to fulfil this role, which aims to improve the health of the population through health promotion, disease prevention, and self-reliance and -determination of community members with regard to their health. According to the WHO and Health and Welfare Canada,[21] health is considered as a resource for community development.

The community-based projects of 89% of respondents focused on PHC components of health promotion. Also, 90.1% of community-based projects focused on prevention of illness, injuries and social problems, and 45.1% of respondents conducted community-based projects focused on rehabilitative care of patients with deformities, elderly patients with chronic illnesses and mentally ill clients.

This study revealed that 52.7% of respondents conducted communitybased projects on the treatment of common illnesses and injuries at home, such as treatment of lice, diarrhoea and vomiting, flu and minor burn injuries, and 76.9% carried out projects on promoting community self-reliance and -determination, such as identifying, accessing and using available resources in the community to address health-related issues.

The findings are congruent with the results of studies conducted elsewhere,[15, 22-24] which showed that nursing students in CBE implemented various health-promotion and disease-prevention programmes to vulnerable groups, targeting diabetes, heart diseases, safe sexual behaviours and prevention of infectious diseases, such as sexually transmitted infections, tuberculosis, and HIV and AIDS. The health-promotion and diseaseprevention programmes incorporated immunisation, oral health, infant feeding, hygiene products, transmission of germs, preparation for cold weather, healthy eating, womenâ&#x20AC;&#x2122;s health issues and assessment of blood pressure for adults. These studies revealed that CBE has a positive impact on the lives of target groups, while enabling the learners to become socially

Research responsible and respond to the needs of the community, especially those who are underserved and vulnerable.[5,25,26] The community-based nursing education programme is in line with recommendations of the DoH,[11] DoE,[10] SANC and various other inter­ national organisations. These institutions stipulate that the education of healthcare professionals should be responsive to community needs in achieving learning objectives by actively involving students in learning experiences that bring about change in the community.[6,7,10,11,27] The literature maintains that this approach provides comprehensive learning experiences that focus on health promotion, illness prevention, treatment, and rehabilitation, and that it promotes self-reliance and -determination of the community.[1,2] Education is therefore linked to PHC, making PHC philosophy a driving force in healthcare in the world and in SA in particular.[1,3,5, 7,13,28] Students’ community-based learning projects focused on providing healthcare services according to the needs of the community. As a social justice teaching approach,[29] this enhanced accessibility of the health service to underserved areas, thus promoting equity in healthcare services provision, which is in accordance with the social justice orientation of the PHC philosophy. One of the principles of PHC is equity in healthcare provision, with the ultimate goal of changing the lives of the population being served. Equity in healthcare delivery has been reiterated in the PHC Declaration of Alma-Ata.[3] The findings are in line with the recommendations of the Lancet report of 2010, stipulating that the curriculum of health professionals should equip them with competencies to practise at community level, where they provide PHC services focusing mainly on health promotion and prevention of diseases. It further stipulates that health professionals should learn to work in teams, as maintenance and restoration of health depend on multiskilled professionals.[30] This study shows that the educational experiences of students in the community incorporate the essential elements of PHC and are consistent with the aims of the Alma-Ata declaration,[3] i.e. to address the health problems of a community by making healthcare services accessible to them and by promotive, preventive, curative and rehabilitative healthcare education and services to prevent diseases and improve health.

Our findings are congruent with the results of the study conducted in SA by Mtshali,[1] who found that learning experiences in community-based nursing education exposed students to a number of strategies aimed at promoting and improving the health status of the population, especially those from underserved and poor groups. The strategies included growth monitoring, oral rehydration, breastfeeding, immunisation, female literacy as women empowerment, family planning, food supplementation to prevent malnutrition, and first aid at home, also known as the GOBI-FFFF strategy by the United Nations Children’s Fund (UNICEF).[31] The results of this study showed that community-based learning exposes nursing students to educational experiences that prepare them to fulfil the roles of health promoters, health educators, community and vulnerable group advocators, promoters of community self-reliance and -determination, and members of interdisciplinary teams working together to improve the health of individuals and groups, which according to Keleher et al.[32] are the roles of nurses in PHC settings. The findings revealed that community-based learning activities enhance and promote PHC.

Conclusion

Community-based nursing education as an educational approach provides students with an opportunity to learn and provide services to communities.

The findings show that the students involved community members in their community-based service-learning experience. Students engaged in CBE projects that focused on health promotion, prevention of illnesses, injuries and social problems, treatment of minor illnesses, rehabilitative care and promotion of community self-reliance and -determination. These projects and other learning experiences are linked to PHC principles, thus providing healthcare services to vulnerable groups and promoting equity in healthcare access. This familiarises students with principles of PHC, as these principles were instilled during training and therefore promoted a PHC philosophy. This study revealed that a CBE programme promotes PHC philosophy.

References 1. Mtshali NG. Implementing community-based education in basic nursing education programs in South Africa.

Curationis 2009;32(1):25-32.

2. World Health Organization (WHO). Increasing the Relevance of Education for Health Professionals.

Report of WHO Study Group on Problem Solving Education for Health Professionals. Geneva: WHO, 1993.

3. WHO and United Nations Children’s Fund ( UNICEF). International conference on primary healthcare. AlmaAta, USSR, 6 - 12 September 1978.

4. International Council of Nursing (ICN). Reducing the gap and improving the interface between education and service: A framework for analysis and solution generation. 2009. http://www.icn.ch/images/stories/documents/ publications/free_publications/reducing_the_rap.pdf (accessed 7 August 2012).

5. WHO. Community-based Education of Health Personnel. Report of a WHO Study Group. Geneva: WHO, 2012.

6. Mekwa J. Transformation in nursing education. http://www.healthlink.org.za/uploads/files/chapter13_00.pdf. (accessed 27 May 2014).

7. Mthembu SZ, Mtshali NG. Conceptualisation of knowledge construction in community service learning programmes in nursing education. Curationis 2013;36(1):69-79.

8. Okayama O, Kajii E. Does community based education increase students’ motivation to practice community health care? A cross sectional study. British Medical Council Medical Education 2011;11:19. [http://dx.doi.org/ doi:10.1186/1472 -6920-11-19] 9. Kaye DK, Mwanika A, Sewankambo S. Influence of the training experience of Makerere University medical and nursing graduates on willingness and competence to work in rural health facilties. Rural and Remote Health 2010;10(1):1-9.

10. Department of Education, South Africa. White Paper for the Transformation of the Health System in South Africa. Pretoria: Department of Education, 2013. http://www.healthlink.org.za/pphc/Phila/chap01-4.htm (accessed 27 January 2014).

11. Department of Health, South Africa. White Paper for the Transformation of the Health System in South Africa.

Pretoria: Department of Health, 2012. http://www.info.gov.za/whitepapers/1997/health.htm (accessed 28 March 2012).

12. Gumbi RV, Muller ME. Health personnel education in South Africa. Health SA Gesondheid 1996;1(3):36-40.

13. Fichard AE, du Rand PP. Facilitators’ perceptions of problem-based learning and community-based education.

Health SA Gesondheid 2000;5(2):3-10.

14. Mtshali NG. Developing a community-based nursing education curriculum. In: Uys LR, Guele NS, eds.

Curriculum Development in Nursing Process and Innovation. New York: Routledge, 2005.

15. Sullivan CH. Educational innovations. Partnering with community agencies to provide nursing students with cultural awareness experiences and refugees health promotion access. Journal of Nursing Education 2009;48(9):519-522.

16. Lenz BK, Warner S. Global learning experiences during a domestic community health clinical. Nursing Education Perspectives 2011;32(1):26-29.

17. Bentley R, Ellison KJ. Impact of a service learning project on nursing students. Nursing Education Perspectives 2005;26(5):287-290.

18. Uys LR, Gwele NS. Curriculum Development in Nursing: Process and Innovation. New York: Routledge, 2005.

19. Australian Capital Territory. PHC strategy 2011 - 2014. 2010. http://www.health.act.gov.au/c/health?a=sendfile& ft=p&fid=1299734305&sid (accessed 18 April 2012).

20. Institute for Sustainable Communities. Community-based approach to education for sustainability. Developing a new generation for leaders through school-based programs linked to community issues. 2011. http://www.iscvt. org/who_we_are/publications/Education%20for%20Sustainability%20Guidebook.pdf (accessed 20 November 2012).

21. WHO and Health and Welfare Canada. Ottawa Charter for Health Promotion. An International Conference on Health Promotion, 17 - 21 November 1986, Ottawa, Canada. Geneva: WHO, 1986.

22. Reising DL, Shea RA, Allen PN, et al. Using service learning to develop health promotion and research skills in nursing students. International Journal of Nursing Education Scholarship 2008;5(1):1-18.

23. Eriskson GP. Community health nursing in a non-clinical setting: Service-learning outcomes of undergraduate students and clients. Nurse Educator 2004;29(2):54-57.

24. Lashley M. Nurse on a mission: A professional service learning experience with the inner-city homeless. Nursing Education Perspectives 2007;28(1):24-26.

25. Lazarus J, Erasmus M, Hendricks D, et al. Embedding community engagement in South African higher education. Education, Citizenships and Social Justice 2008;3(1):57-83.

26. Vogt MA, Chevez R, Schaffner B. Baccalaureate nursing student experiences at a camp for children with diabetes: The impact of a service learning model. Pediatric Nursing 2011;37(2):69-73.

27. Whelan J, Spencer J, Rooney K. A ‘RIPPER’ project: Advancing rural interprofessional health education at the University of Tasmania. Rural and Remote Health 2008;8(3):1017-1022.

28. Mtshali NG. A Grounded Theory Analysis of the Meaning of the Community-based Education in Basic Nursing Education in South Africa. PhD thesis. Durban: University of KwaZulu-Natal, 2003.

29. Henry J. Meaning and practice in experiential learning. In: Weill SW, McGill I, eds. Making Sense of Experiential Learning: Diversity in Theory and Practice: Buckingham: SRHE and Open University Press, 1993.

30. Frenk J, Chen L, Bhutta ZA, et al. Education of health professionals for 21st century. Health professionals for new century: Tranforming education to strenghten health systems in an independent world. Lancet 2010;376:19231958. [http://dx.doi.org/10.1016/S0140-6736(10)61854-5] 31. WHO. Research for Universal Health Coverage: World Health Report. Geneva: WHO, 2013.

32. Keleher H, Parker R, Francis K. Preparing nurses for primary healthcare futures: How well do Australian nursing courses perform? Australian Journal of Primary Health 2010;6(3):211-216.

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Research Dental students’ perceptions of practice management and their career aspirations S E van der Berg-Cloete, BChD, PGDip (Com Dent), MBA, DHSM; L Snyman, BChD, PGDip (Clin Dent), PGDip (Prac Man), PGCHE, MBL; T C Postma, BChD, MChD (Com Dent), DHSM, PhD; J G White, BChD, BChD (Hons), Dipl Tertiary Education, MBA, PhD Department of Dental Management Sciences, School of Dentistry, Faculty of Health Sciences, University of Pretoria, South Africa Corresponding author: S E van der Berg-Cloete (sophy.vanderberg-cloete@up.ac.za)

Background. The inclusion of ‘management’ competencies in medical curricula is widely propagated. There is some evidence in the literature that undergraduate dental students regard clinical skills as more important than management skills.

Objective. To investigate student perceptions regarding Dental Practice Management (DPM) as a subject in the undergraduate dental curriculum at the University of Pretoria, South Africa (SA) and to relate these perceptions to their future career aspirations.

Method. A cross-sectional survey was conducted in 2012 by means of an anonymous questionnaire among second-, third-, fourth- and fifth-year dental students (N=228) at the University of Pretoria’s School of Dentistry.

Results. Of the 192 respondents, 92% (n=177) agreed that DPM should be a subject in an undergraduate curriculum, but there was no correlation with their career aspirations. Leadership and management skills (77.6%), people skills (64.6%), communication and listening skills (46.4%) and personal style (42.2%) were seen as the most important non-clinical skills. Students indicated their career aspirations as follows: private practice owners (45.3%, n=81), public sector and military (15.1%, n=27), working abroad (13.4%, n=24) and Medicross/Intercare (11.2%, n=21). There were statistically significant differences (p=0.001) among the study years with regard to private practice aspirations. Most students (81.7%, n=156) indicated that they would specialise if afforded the opportunity.

Conclusion. In light of the prospects of the National Health Insurance (NHI) in SA, management and leadership skills will be vital to the successful longterm implementation of the NHI; hence, academic institutions and government should address these issues as a priority in their undergraduate curricula.

Afr J Health Professions Educ 2015;7(2):194-198. DOI:10.7196/AJHPE.408

The inclusion of ‘management’ competencies in medical curricula is widely propagated.[1-3] Partly based on this requirement, Dental Practice Management (DPM) is part of the undergraduate curriculum in the School of Dentistry, University of Pretoria, South Africa (SA). In recent years, DPM has been presented in the fourth and fifth years of study and can be considered a major study unit in the undergraduate dental curriculum.

Teaching and learning in DPM typically include leadership, strategic management, financial management, personnel management, patient management, dentist-patient communication and marketing.[4] To date, from a student perspective, no information is available regarding the need for DPM as a subject in undergraduate dental curricula in SA. There is, however, some evidence in the literature that undergraduate dental students do not regard the development of management skills to be as important as the attainment of clinical skills.[5] DPM is likely to be relevant to those who aspire to become dental practice owners or managers in the private or public sector. It is debatable whether extensive teaching and learning in DPM will be perceived to be relevant by those who aspire to follow a career as employees only.

The literature shows that the majority of dental graduates in SA aspire to enter private practice.[6] These trends may, however, be affected by the transformation in dental education during the past two decades.

During this time, the profile of dental students changed from being male dominated to female dominated.[6] Furthermore, social redress in correcting racial profiles at universities is actively being pursued.[6] It would therefore be valuable to investigate whether these demographic changes affect the career aspirations of dental students and if DPM

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is perceived to be relevant and necessary as a major subject in the undergraduate dental curriculum.

This study sought to investigate students’ perceptions regarding the need for DPM as a subject in the undergraduate dental curriculum at the University of Pretoria and to relate these perceptions to their future career aspirations. The study also aimed to identify perceptions of the students regarding the most important skills (other than clinical skills) they have to learn in the undergraduate dental curriculum.

Methods

A cross-sectional survey was conducted in 2012 by means of an anonymous questionnaire among second-, third-, fourth- and fifth-year dental students (N=228) at the University of Pretoria’s School of Dentistry. The Research and Ethics Committees at the Faculty of Health Sciences, University of Pretoria approved the study protocol (91/2012).

Sample

Second-, third-, fourth- and fifth-year dental students (N=228) at the University of Pretoria’s School of Dentistry were invited to take part in the research.

Questionnaire design

In this pilot study a custom-designed questionnaire, in English, with open- and closed-ended questions, was administered to the various cohorts; participation was voluntary and anonymous. The questionnaire was not piloted before.

The researcher distributed the questionnaires to the students at the start of a routine lecture period (around midday). The students completed a consent

Research form, which clearly stated that participation in the study was voluntary and that they could refuse to participate or discontinue at any time without giving a reason. The researchers collected the completed questionnaires immediately on completion.

Participants were asked to indicate their year of study, race and gender. They also had to specify whether they would wish to specialise if given an opportunity. Information on their previous exposure to public, military and private dental institutions was also elicited. Furthermore, students had to state their long-term career aspirations. They were asked whether they would prefer to work as an employee in the public sector, military, at Medicross/Intercare (managed healthcare provider) or for a private dentist.

Alternatively, they could indicate whether they aspired to become a dental practice owner or business partner in a dental practice. An option was also provided to specify whether they wished to work abroad.

There was an open-ended question regarding the ‘important skills other than clinical skills’; students had an option to indicate the four most important skills in terms of keywords. Their responses were thematically coded.

Students then had to respond to whether they thought that DPM should be a subject in an undergraduate dental curriculum. The questionnaire contained a Likert scale response choice of ‘strongly disagree’, ‘sometimes disagree’, ‘disagree’, ‘sometimes agree’ ‘agree’ or ‘strongly agree’ for the majority of the questions. An open-ended question where students were asked to write a reflection on why they thought DPM should/should not be a subject in an undergraduate dental curriculum, was also thematically coded.

Data analysis

The coded data were captured on an Excel spreadsheet and analysed using SPSS version 21.

Descriptive statistics included determination of frequencies. The χ2 test was used for bivariate associations between demographic variables (year of study, sex, race) and students’ perception of DPM as a subject in an undergraduate dental curriculum, their long-term career aspirations and their specialisation aspirations. A value of p<0.05 was considered statistically significant.

Results

Of the 228 targeted students, 192 (84%) completed the questionnaire. The number of students per year of study varied between 39 and 59.

Less than half (45.3%, n=81) of respondents (Table 2) indicated their aspirations to become private practice owners, i.e. 50% (n=31) males and 42.7% (n=50) females. At least 44 (49.4%) of the white students indicated their intention to become private practice owners, while 39.7% (n=23) of black students indicated this option. These differences were not statistically significant.

Some respondents (15.1%, n=27) (Table 2) mentioned that they intended to work in the public sector or the military. Furthermore, 29.3% (n=17) of black students stated that they want to be employed in the public sector or in the military, while only 6.7% (n=6) of white respondents select­ ed this option (χ2 test, p<0.001). Twenty-one per

Table 1 indicates that the respondents were mainly female (66.1%, n=127); 49.5% (n=95) were white, 33.0% (n=64) black, 11.5% (n=22) Asian, and 2.6% (n=5) coloured. The remaining 3.1% (n=6) students did not indicate their race. The responses of students from Asian descent were similar to those of the white students. Similarly, the responses of the coloured students generally followed the trend of the black respondents. No further mention, therefore, is made in the results of the two minority groups of self-reported race.

The majority (92%, n=177) of students agreed that DPM should be a subject in an undergraduate dental curriculum. Responses to an open-ended question where students had to write a reflection on why they thought DPM should/should not be a subject in an undergraduate dental curriculum, included: ‘It is as important as clinical skills’; ‘It will help to run a business/private practice’; ‘It will assist us in knowing the external environment’; ‘It prepares one for what to expect in the business world’; ‘We as undergraduates may not see the importance now and may forget some information but one can see the role that it will play one day’.

Fig. 1 displays important skills other than clinical skills as perceived by the students. These include: (i) leadership and management skills (77.6%), such as teamwork, motivation, time-management, finan­cial management, business and decision-making skills; (ii) people skills (64.6%), such as sympathy, caring, kindness, empathy, compassion and friend­ liness; and (iii) communication and listening skills (46.4%), and personal style (42.2%), such as thoroughness, tolerance, patience, positive attitude, enthusiasm and self-discipline. Skills pertaining to ethics and professionalism, and entrepreneurial skills were mentioned less often.

Table 1. Breakdown of students’ gender, race and year of study n

%

Female

127

66.1

Male

65

33.8

Black

64

33.3

Coloured

5

2.6

Asian

22

11.5

White

95

49.5

Not reported

6

3.1

BChD II

43

22.4

BChD III

59

30.7

BChD IV

39

20.3

BChD V

51

26.6

Total

192

Variable Gender

Self-reported race

Year of study

2.1

Other (e.g. research, IT)

6.3

Entrepreneurial skills

10.4

Professionalism

17.2

Ethics

42.2

Personal style

46.4

Communication and listening skills

64.6

People skills

77.6

Leadership and management skills 0

10

20

30

40

50

60

70

80

90

Percentage Fig. 1. Students’ perceptions of important non-clinical skills (IT = information technology).

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Research cent (n=21) of male respondents compared with 12% (n=12) of female respondents were interested in working in the public sector or in the military.

This difference was not statistically significant.

At least 13.4% (n=24) of the total respondents (Table 2) expressed an intention to work overseas. A larger proportion of white respondents (14.6%, n=13) than black respondents (5.2%, n=3), which included a higher ratio of males (16.1%, n=10) than females (12.0%, n=14), indicated their intent to work overseas (not statistically significant).

A further 11.2% (n=21) of respondents (Table 2) displayed an interest in working at Medicross/Intercare. The ratio of female respondents (15%, n=17) interested in this option exceeded the ratio of male (7%, n=4) res­ pondents (not statistically significant). There was virtually no difference between the white (11.2%, n=10) and black (12.1%, n=7) students regarding the Medicross/Intercare option.

Table 2 further indicates that 8% of the respondents (n=15) displayed an interest in working as an employee for a private dentist. White respondents

Table 2. Career aspirations of second- to fifth-year dental students

Self-reported race and gender

Public sector/ military

Medicross/ Intercare

Work as employee for private dentist

Academic

Private dental practice owner

No career option indicated

Overseas

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Black (female)

7

25.0

4

14.3

2

7.1

3

10.7

10

35.7

2

7.1

Black (male)

10

33.3

3

10.0

1

3.3

2

6.7

13

43.3

1

3.3

Black (subtotal)

17

29.3*

7

12.1

3

5.2†

5

8.6

23

39.7

3

5.2

Coloured (female)

1

25.0

1

25.0

2

50.0

Coloured (male)

1

100.0

0

0.0

0

0.0

Coloured (subtotal)

2

40.0

1

20.0

2

40.0

Asian (female)

2

10.5

2

10.5

1

5.3

8

42.1

6

31.6

Asian (male)

0

0.0

1

33.3

0

0.0

2

66.7

0

0.0

Asian (subtotal)

2

9.1

3

13.6

1

4.5

10

45.5

6

27.3

White (female)

4

6.5

10

16.1

12

19.4

3

4.8

28

45.2

5

8.1

0

0.0

White (male)

2

7.4

0

0.0

0

0.0

13.5†

0.0

16

59.3

8

29.6

1

3.7

White (subtotal)

6

6.7‡

10

11.2

12

13.5†

3

3.4

44

49.4

13

14.6

1

1.1

Race not reported (female)

2

50.0

1

25.0

1

25.0

Race not reported (male)

0

0.0

1

100.0

0

0.0

Race not reported (subtotal)

2

40.0

2

40.0

1

20.0

Female (subtotal)

14

12.0

17

14.5

14

12.0‡

7

6.0

50

42.7

14

12.0

1

0.9

Male (subtotal)

13

21.0

4

6.5

1

1.6‡

2

3.2

31

50.0

10

16.1

1

1.6

Total * † ‡

27

15.1

21

11.7

15

8.4

9

5.0

81

45.3

24

13.4

2

1.1

p<0.001 (χ2 test). p<0.05 (Fisher exact test). p<0.05 (Fisher exact test).

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Research (13.5%, n=12) were more likely to indicate this option than black respondents (5.2%, n=3) (Fisher exact test, p<0.05). Similarly, female respondents (12%, n=7) were more inclined to select this option than males (1.6%, n=1) (Fisher exact test, p<0.05).

Of the total respondents, 5% (n=9) indicated an interest in becoming an academic, while 1.1% (n=2) did not indicate their future career aspirations (Table 2).

It should be noted that no statistically significant association could be found between the students’ career aspirations and their perception about the need for DPM in the undergraduate dental curriculum.

Most students (81.7%, n=156) felt that they would specialise if they were afforded the opportunity.

Less than half (43.2%, n=83) of the respond­ ents had previous exposure to public or military service. Only 39.6% (n=76) had exposure to Medicross/Intercare, while the majority (88.0%, n=169) had visited a private dental practice before. No statistically significant association could be shown between the students’ previous experiences of private and public dental care facilities and their potential career choices.

Discussion

This study investigated the perceptions of dental students with regard to the need for DPM as a major study unit in an undergraduate dental curriculum.

The findings of the current study that the majority of dental students who responded to the questionnaire considered DPM to be a necessary field of study in the undergraduate dental curriculum at the University of Pretoria, correspond to similar research carried out abroad.

The latter studies reported that students studying health sciences are indeed becoming increasingly aware of the need for business training.[7-9] Qualified practising dentists also recognise the need for DPM education in the curriculum.[10] The findings of the current study are, however, unique, as they provide the first indication of dental students’ perceptions regarding the need for DPM in SA. Clinical skills are generally considered extremely important, but ‘soft’ skills such as leadership, communication and DPM contribute to the success of practising health professionals.

Its importance in an undergraduate curriculum has been acknowledged.[11-13] The development of management skills is therefore becoming crucial for dentists to manage their practices successfully.[14-16]

These skills are often neglected in undergraduate curricula despite tendencies that students recognise them as crucial.[17-20] In our study, students were asked to indicate the most important skills – other than clinical skills. From their responses it could be deducted that leadership and management were considered to be the most important skills to acquire other than clinical skills. This study is the first to point out that dental students regard leadership and management as priority skills.

The students’ perception that DPM should be part of the dental curriculum at the University of Pretoria is probably the result of their awareness of the complexity of the dental practice ‘business’ environment and changes facing dentists in the external environment.[21] These features are actively addressed in the undergraduate dental curriculum from the second year of study onwards as part of the Integrated Dentistry module (second year of study) and Comprehensive Patient Management (CPM) module (third to fifth year of study) (CPM study guide – available from the authors).

Another possible reason for the overwhelming response that DPM should be a subject in the undergraduate dental curriculum may reflect the students’ career aspirations. No associations could, however, be found between the career aspirations of the students and their opinion about the need for DPM as a subject, also not when analysed in terms of the year of study. A few local and international studies have suggested that the majority of students opt for private practice rather than the public sector.[6,22-25] About 45.3% of the students indicated a vision of owning a private dental practice, with only 15.1% showing a desire to work in public health facilities or in the military. These findings are not surprising, as it is well known that government and the military have a fixed number of posts and many of the governmental posts in SA are annually filled by dentists in community service. Private dental practice is, therefore, the most viable part of the market for a qualified dentist for employment in SA. The potential future strengthening of the public sector by means of the National Health Insurance (NHI) may, however, change these perceptions. In a study done in the UK, where there is a well-established National Health Service (NHS) with ample employment opportunities, a high ratio of students indicated an intention to work in the NHS.[26] Another interesting finding of the current study is the much higher ratio of black students who indicated an interest to work in the public sector or the military compared with white students.

The findings illustrate that, compared with males, female students (especially white females) who do not aspire to become private practice owners want to become employees in a private dental practice or work at institutions such as Medicross or Intercare. These trends are important to monitor in future as female dental students are in the majority.

The abovementioned findings are indicative of differences that may exist among dental students with regard to career aspirations. This is important in SA, where political redress is continuously taking place. In the current study, white students are ~50% of the study sample, which is not reflective of the demographic profile of the country.

The racial profile at the University of Pretoria is however normalising over time, i.e. a higher ratio of black students will graduate in future. The study showed significant differences between the career aspirations of white and black students. It is important for tertiary institutions to be aware of the changing career aspirations of the emerging oral healthcare workforce, as this will assist in future planning and policy decisions in terms of the content of dental curricula. The current study provides valuable local data in this regard.

The results also highlighted that the majority of the dental students at the University of Pretoria would specialise if they were afforded the opportunity. Conflicting evidence in this regard is available in the literature. Freire et al.,[22] Grytten and Skau[27] and Rashid et al.[28] showed that the majority of students wish to specialise, while Marino et al.[23] and Drinkwater et al.[29] indicated that the majority of students wanted to be general dentists only. Male students were more likely to specialise, while females preferred to pursue an academic career.

The findings also suggest that only a small percentage of local dental students are interested to employ their skills abroad. The relatively low percentage probably results from South Africans having to pass an examination abroad (since 2000). It has become increasingly difficult for SA dentists to be employed in countries such as the UK.[30]

Conclusion

The two main findings of this study are as follows: • Second- to fifth-year dental students are of the opinion that DPM is an important part of the dental curriculum at the University of Pretoria and regard leadership and management skills as being as important as clinical skills.

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Research • Sociodemographic differences exist in the career aspirations of dental students, which is important to take into account given the changing demographic profile of dental students.

The greatest limitation of the current study is that the results are merely a snapshot of students’ perceptions at a single university in SA at a given point in time. The results can therefore not summarily be generalised with regard to other training institutions. This research should, however, be expanded to a national level, incorporating all the dental training institutions through a collaborative effort to investigate the need for management and leadership training. The questionnaire used in this pilot study appears to have rendered reliable results and can serve as the basis for future research. The opinions of academics and dentists from both the public and private sectors should also be sourced in future research projects.

Acknowledgements. The researchers acknowledge the positive attitudes and cooperation and inputs of the participating students. We thank Barbara English, Research Office, Faculty of Health Sciences, University of Pretoria for her editing skills.

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11. Hobson RS. Challenges to future dental education. Br Dent J 2009;206(3):125-126. [http://dx.doi.org/10.1038/ sj.bdj.2009.54] 12. Jawale BA, Bendgude V, Husain N, Thosar N, Tandon P. Soft skill appraisal for dentistry: A tool for positive practice management. J Contem Dent Pract 2011;12(6):475-478.

13. Plasschaert A, Lindh C, McLoughlin J, et al. Curriculum structure and the European Credit Transfer System for European dental schools: Part I. Eur J Dent Educ 2006;10(3):123-130.

14. Bajaj A. Good management underpins good clinical dentistry. Vital 2010;7(4):16-18.

15. Dunning DG, Lange BM, Madden RD, Tacha KK. Prerequisites in behavioural science and business: Opportunities for dental education. J Dent Educ 2011;75(1):77-81.

16. Willis DO. Using competencies to improve dental practice management education. J Dent Educ 2009;73(10):1144-1152.

17. Abbas MR, Quince TA, Wood DF, Benson JA. Attitudes of medical students to medical leadership and management: A systematic review to inform curriculum development. BMC Med Educ 2011;11(93):1-21. [http:// dx.doi.org/10.1186/1472-6920-11-93] 18. Kalenderian E, Timothé P. Integrating leadership into a practice management curriculum for dental students. J Dent Educ 2010;74(5):464-471.

19. Lennon MA, Ireland RS, Tappin J, et al. The personal dental service as a setting for an undergraduate clinical programme. Br Dent J 2004;196(7):419-422.

20. Slavkin HC, Lawrence L. Incorporating leadership knowledge and skills into the dental education community. J Dent Educ 2007;71(6):708-712.

21. White JG. Interacting forces influencing private dental practice in South Africa: Implications for dental education. S Afr Dent J 2008;63(2):80-85.

22. Freire MCM, Jordao LMR, de Paula Ferreira N, de Fatima Nunes M, Queiroz MG, Leles CR. Motivation towards career choice of Brazilian freshman students in a fifteen-year period. J Dent Educ 2011;75(1):115-121.

23. Mariño R, Au-Yeung W, Habibi E, Morgan M. Sociodemographic profile and career decisions of Australian oral health profession students. J Dent Educ 2012;76(9):1241-1249.

24. Scarbecz M, Ross JA. The relationship between gender and postgraduate aspirations among first- and fourth-year students at public dental schools: A longitudinal analysis. J Dent Educ 2007;71(6):797-809.

25. Stewart F, Drummond J, Carson L, Theaker E. Senior dental students’ career intentions, work-life balance and retirement plans. Br Dent J 2007;203(5):257-263.

26. Gallagher JE, Patel R, Wilson NHF. The emerging dental workforce: Long-term career expectations and influences. A quantitative study of final year dental students’ views on their long-term career from one London Dental School. BMC Oral Health 2009;9(35):1-9.

27. Grytten J, Skau I. Specialization and competition in dental health services. Health Economics 2009;18(4):457-466.

28. Rashid HH, Ghotane SG, Abufanas SH, Gallagher JE. Short and long-term career plans of final year dental students in the United Arab Emirates. BMC Oral Health 2013;13(1):1-9.

29. Drinkwater J, Tully MP, Dornan T. The effect of gender on medical students’ aspirations: A qualitative study. Med Educ 2008;42(4):420-426. [http://dx.doi.org/10.1111/j.1365-2923.2008.03031.x] 30. Eaton K, Balázs P. Dentists’ migration to and from Hungary between 1970 and 2005 and into the United Kingdom between 1994 and 2005. Oral Health and Dental Management in the Black Sea Countries 2008;7(4):3-11.

Research Second-year dental students’ perceptions about a joint basic science curriculum T C Postma,1 PhD; L Bronkhorst,2 BChD 1

Department of Dental Management Sciences, School of Dentistry, Faculty of Health Sciences, University of Pretoria, South Africa

2

Department of Dental Management Sciences, School of Dentistry, Faculty of Health Sciences, University of Pretoria, South Africa (BChD student at the time of the study)

Corresponding author: T C Postma (corne.postma@up.ac.za)

Background. Medical and dental students often participate in joint basic science curricula, such as the basic science curriculum at the University of Pretoria, South Africa. Reports from the USA and Australia, however, show that it may be problematic because joint basic science curricula are mostly tailored around the needs of the medical students only, which may lead to prejudice and marginalisation of dental students. There are no local studies to inform decision-making in this regard.

Objectives. To determine whether dental students perceived the joint basic science curriculum at the University of Pretoria to be relevant to their needs and if they felt marginalised.

Methods. Reflective essays with regard to the 2011 and 2012 second-year dental students’ perceptions of the first 2 years of study in the joint curriculum were qualitatively analysed using a thematic approach. Frequency distributions of the identified themes were also calculated.

Results. Despite positive comments, the dental students perceived that the joint basic science curriculum at the University of Pretoria may not be relevant to their needs and that they are being marginalised in the teaching and learning processes.

Conclusion. The current study highlights the need for improvements in the manner in which joint basic science curricula are being administered in order to foster interprofessional collaboration. Alternatively, dental and medical students should be separated to ensure that the educational objectives of basic science curricula are being met for minority groups, such as dental students.

Afr J Health Professions Educ 2015;7(2):199-201. DOI:10.7196/AJHPE.409

Globally, medical and dental university students share basic science curricula,[1-6] promoting cost-effectiveness of student training.[7] This strategy ensures that dental students develop a solid medical background. The approach has historical roots,[8] and remains a current teaching and learning requirement for a dentist.[9] The University of Pretoria, South Africa (SA) utilised a joint basic science curriculum for first- and second-year medical and dental students from the late 1940s to 2014.

A recent article by Ajjawi et al.[1] identified the marginalisation of dental students in a combined medical curriculum at a university in Australia. Similarly, a US study showed that dental students felt like ‘second-class citizens’ in their joint curriculum and that its relevance was based on the needs of the medical student; it also contained too much irrelevant information from a dental perspective.[3] Ajjawi et al.[1] suggest that prejudice and stereotyping may be prevalent in joint basic science curricula. These factors may possibly be present from a social and psychological perspective,[10] when two distinct groups have to interact in a joint curriculum. Medical and dental students sharing a joint curriculum may therefore pose undesired risks with regard to student learning.[1] Despite the identification of these problems, no studies or reports could be traced in the literature that describe how such problems are actively being addressed in terms of medical and dental students.

There are no studies in SA that investigate dental students’ perceptions of their social and peer relationships with medical students in a shared medical curriculum. With the marginalisation of dental students being reported elsewhere,[1] one should investigate this issue in SA. Further evidence in this regard may indicate the need to reconsider the use and management

of generic joint programmes locally in terms of the effect on learning and interprofessional collaboration.

Based on this assessment, our study investigated whether dental students at the University of Pretoria perceive the joint curriculum to be relevant and useful and if marginalisation is prevalent.

Methods

Ethical approval and permission for the study were obtained. Anonymous written student reflections of the 2011 (sample A (n=53)) and 2012 (sample B (n=45)) second-year dental student cohorts from the School of Dentistry, University of Pretoria regarding their experience in the first 2 years of the medical curriculum were retrospectively analysed using qualitative thematic coding methods.[11] The frequency distributions of the coded themes were subsequently studied to complement the qualitative analysis.

The written reflection was open to comments that the students wished to share and specific topics such as marginalisation were not mentioned as part of the instruction, which was as follows: ‘Write a one-page reflection about your experience during the first two years of study.’ The feedback session took place without prior announcement and the students were not allowed to interact during this session. They were encouraged to give both ‘positive’ and ‘negative’ feedback.

Relevant phrases were identified from the responses of the students and were coded, based on the similarity of the comments.[11] ‘Relevance’ and ‘marginalisation’ were pre-empted as key themes. Similar comments were grouped together based on common themes.[11] Provision was made to identify new themes during the course of the analysis, based on the similarity of the students’ responses.[11]

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Research Results

Ninety-eight students representing 80% of the total student population of the 2 second-year cohorts participated in the study. The remaining students in each cohort did not attend the feedback session.

The thematic analysis of the students’ comments included ‘relevance’, ‘marginalisation’ and related topics (Table 1).

Qualitative results – what did the students say?

A selection of quotes from the students’ reflections is given in Table 2.

Quantitative results – positive comments

Forty-two per cent of the students commented that the first 2 years of study were enjoyable, 35% described it as an interesting experience, and 26% and 23% mentioned that the joint curriculum was useful and relevant, respectively. A further 23% suggested that the joint curriculum may be advantageous to a dental student, while 15% remarked that it is ‘good’ practice. At least 12% mentioned that they gained numerous friends during this time, while 11% felt that they grew on a personal level.

Quantitative results – negative comments

More than half (54%) of the participating second-year dental students were of the opinion that the joint curriculum contained too much irrelevant information Table 1. Thematic analysis of the top 20 comments of dental students with regard to their first 2 years of study at the University of Pretoria

(Table 1). Forty-three per cent thought that the medical students were treated superiorly by lecturers compared with dental students and 38% felt excluded during the teaching and learning. The students mentioned that the first 2 years of study were challenging, with an intense scope (28%), and contained too much information (27%). Twenty-one per cent thought that the head and neck anatomy was neglected during the anatomy block. Nearly 1 in 5 students (17%) recommended that dental subjects should be included in the first 2 years of study, while 14% pertinently suggested that the curriculum should be split. Some (14%) perceived the first 2 years of study as being overwhelming, difficult and stressful, while 13% mentioned that the curriculum was conducive to a lack of deep and meaningful study.

Discussion

This study investigated the perceptions of dental students with regard to their participation in a joint medical curriculum at the University of Pretoria. Despite a substantial number of positive comments, it is evident that most of the seemingly negative results of this study correspond to findings of US[3] and Australian[1] studies.

Table 2. Perceptions from samples A and B (Table 1) with regard to the first 2 years in the joint medical curriculum at the University of Pretoria Student perception ‘ ... good experience ... ’ ‘ ... enjoyed the joint medical/dental curriculum ... ’ ‘ ... did not seem to give us any information related to the actual dental field ... ’ ‘ ... demotivating to do work that is not applicable ... ’

Sample A, n

Sample B, n

% of sample (A + B)

• Enjoyable experience

19

22

42

• Interesting experience

14

20

35

• Useful experience

6

19

26

‘ ... medical students are treated as if they are superior to us ... ’

• Relevant

12

11

23

‘ ... we do not have to be in joined field if it does not benefit the group as a whole ... ’

• Professional advantage

11

12

23

• Joint curriculum is a good thing

14

1

15

‘ ... fact that it is more medicine-based than dentistry-based, it does sometimes get you under ... ’

• Gained numerous friends

10

2

12

• Grew on a personal level

1

10

11

• Too much irrelevant information

34

20

54

• Medical students superiorly treated

19

23

43

‘ ...would love to have more hands-on practicals ... just basics so we can feel like dentists ... ’

• Dental students feel excluded

15

22

38

‘... enjoyed anatomy ... especially when we did the head and neck anatomy ... ’

• Challenging, with an intense scope

6

21

28

• Too much information

4

22

27

‘... we were able to have a background about the different diseases and the body as a whole ... ’

• Neglect of head and neck anatomy

12

9

21

‘ ... medical terminology was extremely useful ... ’

• Dental subjects needed

9

8

17

‘ ... maybe one or two dental subjects should be implemented ... ’

• Overwhelming

5

9

14

• Difficult and stressful

3

11

14

‘ ... help a lot if the dentistry faculty could communicate with our different block chairpersons ... ’

Coded theme (student perception) Positive feedback

‘ ... feel it is a waste of time ... ’ ‘ ... more time should, however, have been given to the head and neck chapter ... ’ ‘ ... learned a lot of unnecessary anatomy ... ’

Negative feedback

‘ … dental students have transferred to medical due to the intimidation we have to live with everyday.’

‘ ... would have been better perceived by us dentistry students if we were taken into account ... ’ ‘ ... if medical and dental students were in different classes, I think it would be easier ... ’

‘ ... challenging in terms of workload ... ’

• The joint curriculum should be split

12

2

14

‘ ... both challenging and interesting ... ’

• Lack of deep, meaningful studying

8

5

13

‘ ... you tend to read to pass instead of reading, understanding and pass ... ’

200

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Research The perception of dental students that the joint curriculum contained too much irrelevant information and that they were being marginalised were the two most important findings.

It is conceivable in a resource-constrained environment that faculty will design the curriculum to be applicable to the majority of the learners. It is within this paradox that the conflict and prejudice between the two groups arise.[1] As there are usually more medical than dental students, shared curricula are often designed from a pure medical perspective, which may result in a situation where medical students perceive the curriculum to be relevant to them, while dental students perceive the opposite.[3] Relevance, however, is a key element in adult learning.[12] Adult learners mostly decide what is relevant or not. Participation in a joint curriculum, where one group feels that the content is irrelevant, will most likely lead to a breakdown in the learning processes.[12] A lack of relevance may even neutralise the primary intent of a joint curriculum of providing the dental student with a solid medical background.[13] A large percentage of dental students thought that they are being excluded or stereotyped by faculty and that medical students are considered to be superior, which may be detrimental to the learning process and of little value for interdisciplinary co-operation.

Interdisciplinary co-operation has been propagated recently[2] and is based on three principles: learning ‘together’, ‘from’ and ‘about’ one another to foster collegiality on an equal basis.[2] The last two principles are absent in the current study. The results suggest that sharing a joint curriculum, where one of the groups is given preference, may cause conflict and division among the professions. The relative lack of comment about socialising and collaboration among the group in the written reflections may also suggest that negative perceptions regarding the joint curriculum dominate positive perceptions.

Two choices exist for addressing the situation.

Firstly, the dental and medical curricula could take separate routes. Such an approach may be costly, as some courses may have to be duplicated.

Marginalisation and stereotyping will be eliminated to some degree, but possibly at the expense of interdisciplinary collaboration.

Secondly, being cognizant of the potential threats of a joint curriculum, it could be managed to suit the needs of all parties concerned. Consequently, the fundamentals of adult learning should be embraced:[14] prejudice must be reduced through the support of the institution, equal status between the groups should be actively propagated, and positive expectations need to be encouraged. Furthermore, common goals should be set for both groups, but differences should be highlighted and respected.[14,15] In practice this means that the basic medical sciences should be made more relevant for dental

students within the joint curriculum.[13] Such an adjustment will require greater collaboration and communication between the medical and dental schools and may require additional resources.[13]

Conclusion

The findings of this study are particularly relevant in the African context. Africa is a developing continent with considerable resource constraints. The establishment of joint basic science curricula may therefore be regarded as the most viable option to train students. The findings of the current study provide evidence – for the first time in Africa – that the use of a joint curriculum for medical and dental students may be problematic to facilitate interdisciplinary respect and co-operation, with potentially detrimental consequences from a learning perspective.

Should a joint curriculum be the only option from a resource perspective, the importance of ‘relevance’ of the content in a joint curriculum – as it relates to all parties concerned and the psychological factors of group interaction – should not be underestimated. Ignorance in this regard is likely to result in prejudice[1] and possibly even a breakdown in the learning processes. Possible prejudice or a breakdown of learning processes would refute the original intent of a joint basic science curriculum to equip the dentist with more than only ‘superficial’ basic medical science knowledge.

Acknowledgements. Barbara English of the research office at the Faculty of Health Sciences, University of Pretoria is thanked for the language editing.

References 1. Ajjawi R, Hyde S, Roberts C, Nisbet G. Marginalisation of dental students in a shared medical and dental education programme. Med Educ 2009;43:238-245.

2. Craddock D, O’Halloran C, Borthwick A, McPherson K. Interprofessional education in health and social care: Fashion or informed practice? Learn Health Soc Care 2006;5:220-242.

3. Henzi D, Davis E, Jasinevicius R, Hendricson W. In the students’ own words: What are the strengths and weaknesses of the dental school curriculum? J Dent Educ 2007;71(5):632-645.

4. Martinez-Alvarez C, Sanz M, Bertold P. Basic sciences education in the dental curriculum in Southern Europe.

Eur J Dent Educ 2001;5:63-66.

5. Klineberg I, Massey W, Thomas M, Cockrell D. A new era of dental education at the University of Sydney, Australia. Aust Dent J 2002;47:194-201.

6. Hammick M, Freeth D, Koppel I, et al. A best evidence systematic review of interprofessional education: BME Guide No. 9. Med Teach 2007;29:735-751. [http://dx.doi.org/10.1080/01421590701682576] 7. Pyle M, Andrieu SC, Chadwick DG, et al. The case for change in dental education. J Dent Educ 2006;70:921-924.

8. Formicola AJ. The relationship between dental and medical education: A perspective for the 1990’s. J Dent Educ 1995;59:540-545.

9. Haden NK, Hendricson WD, Kassebaum DK, et al. Curriculum change in dental education, 2003-09. J Dent Educ 2010;74(5):539-557.

10. Tajfel H, Turner T. An integrative theory of intergroup conflict. In: Hogg MA, Abrams D, eds. Intergroup Relations: Essential Readings. Philadelphia, PA: Psychology Press, 2001:94-109.

11. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101.

12. Ashton S. Authenticity in adult learning. Int J Lifelong Educ 2010;29(1):3-19.

13. Baum BJ. Can biomedical science be made relevant in dental education? A North American perspective. Eur J Dent Educ 2003;7(2):49-59.

14. Carpenter J, Hewstone M. Shared learning for doctors and social workers: Evaluation of a programme. Br J Soc Work 1996;26(2):239-257.

15. Hean S, Dickinson C. The contact hypothesis: An exploration of its further potential in interprofessional education. J Interprof Care 2005;19(5):480-491.

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Research Self-regulation – the key to progress in clinical reasoning?

T C Postma, PhD Comprehensive Patient Management, Department of Dental Management Sciences, School of Dentistry, Faculty of Health Sciences, University of Pretoria, South Africa Corresponding author: T C Postma (corne.postma@up.ac.za)

Background. In 2009 a new case-based instructional design was imple­mented during the preclinical year of study of the undergraduate dental curriculum of the University of Pretoria, South Africa. The objective of the educational intervention was to improve the development of clinical reasoning skills. To achieve this, systematic scaffolding, relevance, integration and problem-solving were actively promoted as part of teaching and learning. A student’s clinical reasoning was measured by a progress test containing 32 multiple choice questions (MCQs), formulated on a knowledgeapplication level. In 2011 it became clear that some students showed progression while others did not.

Objectives. This study was conducted to gauge the value of the case-based intervention with the aim of determining the need for further scaffolding and support, especially for non-progressing students.

Methods. The 2011 BChD IV cohort (N=48) was identified for the study. Two semi-structured focus group discussions were conducted. Group 1 (n=8) consisted of students who progressed ≥9%, while group 2 (n=8) comprised students who did not progress to the same extent.

Results. Both groups lauded the scaffolding that the case-based curriculum provided. Strategic thinking, goal orientation and self-regulation ability were identified in group 1. A lack of diligence, poor data-processing ability and a possible lack of interest were identified in group 2 students, who were unaware of learning opportunities.

Conclusion. There is a need for early identification of students lacking self-regulated learning and for providing timely feedback and support to progressively develop their clinical reasoning skills.

Afr J Health Professions Educ 2015;7(2):202-207. DOI:10.7196/AJHPE.411

Institutional context

In 2009 the School of Dentistry, University of Pretoria, South Africa implemented a novel integrated case-based approach during the third (preclinical) year of the undergraduate dental curriculum in a subject called Comprehensive Patient Care (CPC).[1-4] The purpose was to scaffold the transfer from the preclinical year to clinical teaching and learning.[5] The case-based intervention was adopted in pursuit of relevance[5-7] and integration[8] through active learning[9] and problem-solving approaches[2,10].in the undergraduate dental curriculum.[3] The novel intervention aimed to improve the assessment of clinical reasoning[11,12] and the provision of formative feedback during the teaching, learning and assessment processes.[5,12] Teaching and learning in the third year of study were designed to focus on tracer conditions (common oral diseases or conditions)[5,13,14] and were generally administered through scaffolded simulation activities.[5] The assessment plan included a test on the completion of patient administration forms used in the School. This was followed by three communication role-play exercises, simulating the communication during a clinical encounter[15,16] based on context-rich case studies, and a comprehensive clinical examination on a peer. The formative assessment contained 5 integrated clinical reasoning portfolio case-study exercises that simulate typical clinical cases dental students would encounter in their fourth year of study. These exercises included diagnostic and treatment planning decisions and required descriptions of the student’s reasoning. The final assessment comprised a progress test containing 32 multiple-choice questions (MCQs) based on a context-rich integrated case study covering the selected tracer conditions and formulated to test the ability of the students to diagnose and make decisions with regard to treatment planning. Students wrote the same test at the end of the third, fourth and fifth years of study to monitor their progress in their clinical decision-making ability. The progress

202

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test was the only standardised assessment entity that measured the outcome of clinical reasoning over time. The other assessments had a pertinent formative purpose and may have varied; they could therefore not be used to measure the development of clinical reasoning over a period of time.

All of the abovementioned activities have been integrated into clinical teaching and learning in a clinical setting during the fourth and fifth years of study.

The problem

An analysis of progress test data for 2009 - 2011 showed that some students improved their progress test scores while some did not. It should be noted that the non-progression group included students who obtained high, moderate, as well as low scores at baseline. This observation led to the investigation of possible reasons for progression and non-progression in clinical reasoning decision-making. A literature review revealed that psychological attributes such as ‘self-regulated’ learning and ‘self-handicapping’ behaviours may influence the learning of individual students.

The concept of self-regulated learning

Self-regulated learning may be defined as a proactive way of acquiring knowledge, skills and competence.[17] Those who engage in self-regulated learning set goals for themselves, display strategic thinking, and monitor their own academic performance and effectiveness. This is in stark contrast to students who merely react to what the environment enforces on them.[17] Zimmerman and Campillo[18] adapted a model of self-regulated learning from a publication titled ‘The nature of problem solving’. There is increasing empirical evidence to support the validity of the components of the model and the interactions. Fig. 1 demonstrates the three phases of the model. The forethought phase precedes the performance phase, which is followed by a self-reflection phase. Self-reflection is often followed by a new forethought stage for further or enhanced learning.[17]

Research The forethought phase is controlled by task analysis and self-motivation beliefs. Task analysis can be described as a process of strategic planning and the setting of goals. Self-motivation beliefs include goal orientation with self-efficacy beliefs – belief in your own abilities – and an interest in the task at hand, with distinct outcome expectations. For example, expectations of the achievement of ‘excellent’ assessment results could be seen as an indicator of being goal orientated.[17] The second phase is the performance, where self-control and self-observation are the key processes. Self-control is a process of selfinstruction, displaying attention and focus.

The adoption of task strategies and imagery are typical processes employed by self-regulated learners during this phase. Self-monitoring is related to self-control and entails metacognitive monitoring and self-recording practices.[17] The third phase is self-reflection, which consists of self-judgement and self-reaction. Self-judge­ ment includes processes of self-evaluation and causal attribution.[17] The latter may be defined as the reasons (provided by the learner) for the cause of a specific event.[17] The learner might perceive the cause to be from an internal origin (a result of his or her personal behaviour) or an external source.

Self-judgement is followed by self-reaction, based on the individual’s perception of self-satisfaction.

A lack of self-satisfaction might, for example, affectively stimulate a renewed forethought phase to continue the learning. Adaptations to behaviour might also be made as a result of self-evaluation.[17]

Forethought phase • Task analysis • Strategic planning • Goal setting • Self-motivation beliefs • Goal orientation • Self-efficacy beliefs • Interest in the task • Outcome expectations Performance phase • Self-control • Self-instruction • Attention and focus • Task strategies • Imagery • Self-observation • Metacognitive monitoring • Self-recording practices Self-reflection phase • Self-judgement • Self-evaluation • Causal attribution • Self-reaction • Self-satisfaction • Adaptation Return to the forethought phase

Fig. 1. The phases of self-regulated learning.[17]

The concept of selfhandicapping behaviour

Objectives

In contrast to self-regulated learning, there is learning that might be impeded by a student’s personal behaviour.[19] Self-handicapping may be viewed as being in direct contrast to self-regulation.

Some students employ self-handicapping strategies to protect and enhance their self-esteem.[19] Those who employ self-handicapping strategies typically postpone their learning to the last minute and might subsequently blame the circumstances and the external environment rather than their lack of ability, motivation, and diligence.[19] Those who are guilty of self-handicapping behaviour tend to project their lack of performance or failures away from themselves in an attempt to protect their own ability and self-worth.[20,21] Self-handicapping has a negative correlation with a goal-setting approach in the academic environment.[22]

–20

–15

–10

–5

Focus group 2

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48

The first objective of this study was to compare qualitative feedback from progressing and nonprogressing fourth-year dental students with regard to the value of the case-based intervention they were exposed to in the preclinical year of study.

The second objective was to identify selfregulating and self-handicapping behaviours[17,18] among the students, based on the differences in feedback.

The third objective was to determine the need for additional student support to improve the educational intervention further.

Methods

As the current study was part of a larger action research project that originated before 2009, the original protocol (153/2009) was amended in 2011 to include the following qualitative analysis

5

10

15

20

25

Focus group 1

Fig. 2. Distribution of the individual progress test score (%) differences between 2011 and 2010 for the 2011 BChD IV cohort (N=48).

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Research as part of the evaluation of the newly implemented integrated case-based approach.

Sample selection

The 2011 fourth-year BChD cohort was identified because they had the opportunity to clinically apply the knowledge they had gained in the preclinical (third) year of study. These students had completed the progress test more than once; therefore, their progress could be tracked.

The fifth-year group, who were in the final phase of their undergraduate course at that stage, were not interviewed because of time constraints.

Study design

The researcher identified semi-structured focus group discussions as the method of choice for data collection. Such groups maintain a broad structure but allow for flexibility during the interview so that students may elaborate

on their experiences. This may lead to the discovery of information that might have been restricted by an overly structured approach.[23] Two groups of 8 students each from the 2011 fourth-year cohort were purposively selected by the researcher for focus group discussions.[23] These groups were arbitrarily differentiated according to their progression in terms of clinical reasoning (Fig. 2) (measured by means of the progress test), which has been described in the introduction. Focus group 1 consisted of students who appeared to have improved their progress test scores by ≥9%. Focus group 2 comprised students who had either achieved lower progress test scores or had improved their progress test scores by ≤6%.

Informed consent

The students gave written informed consent for their feedback to be included as part of the research project.

Table 1. Positive student feedback about the value of the third-year case-based intervention in preparation for clinical teaching and learning Focus group 1

Focus group 2

Relevance

Relevance

• ‘I also feel it was very, very relevant and the fact that it is such a practical subject. You go out, you do the sessions, you take the patient as a case and you do it. It is not just theory that you have to go and study. ... So, it is practical and it is hands-on and also the type of information that is really useful. It is things that you use every single day. It is the reason behind the theory.’

• ‘I think it is very relevant and I learned a lot from it.’ (Translated from Afrikaans into English)

Integration

Integration

• ‘So, in this subject you learn a little bit of this, and a little bit of that, and then when we got to do the treatment plan. Everything comes together; you know where everything fits in, and how this affects that, and that affects that.’

• ‘ … OPB is, like, the whole holistic thing … .’

• ‘ … and your perio, caries and endo and all those stuff … everything is in there. So if you go through it you won’t be surprised in the following year like [in] the fourth year. So, once you get that a patient ... is full [of] pain … high blood pressure … everything together.’

• ‘ … because this is a subject that basically puts everything together, yes, that is cool.’

Scaffolding

Scaffolding

• ‘ … at the end when you knew what to do, it helped a lot to get your thinking right because you knew, okay, this is the way I have to … .’

• ‘ … and you also learn a lot of, like, diseases and names of things, and how to diagnose it … and do the treatment for it. So it helped a lot for me.’

• ‘I mean we’ve started the year on the 4th floor … and we’ve started looking in the mouth and we knew exactly what to do.’

• ‘Okay, it did help a lot and I think it is a good thing that we have that. If we didn’t have that we would have been totally lost with your first patient. I would have freaked out; I can’t handle that.’

• ‘We are going to use treatment planning for the rest of our lives with all our patients, and if we didn’t learn it step by step with a good foundation then we never would have known how to do it. Yes, it really helped a lot. I think it gave us a good foundation.’

• ‘It helps you, like, thinking on how to treat the patient, and you will actually have that much more confidence. The patient will also see that this person exactly knows what to do… .’

• ‘ … and then [it] also teaches you a lot about treating complex cases.’

• ‘I was pretty, pretty nervous when I saw my first patient, only to find out that, luckily, I knew something.’

• ‘I think it sets the basis from where you can work. It’s a lot different when you get a new patient rather than a friend … but it gives you a guideline from where you can work to, or what you can work from, or how to diagnose different caries and erosion and attrition … So it was a good baseline for us to work from.’

• ‘I also think the third-year cases really helped in putting a base on how to handle a patient, and all that, so it does help. So it must continue.’

• ‘ … for me, I feel it did really help a lot, like I don’t think it should be changed on my side because I feel, like, okay, on some patients you won’t be able to encounter everything, not all patients have the same problems …, so I feel the cases did add something that you didn’t, maybe, know, or see firsthand. So, for me it really did help.’

• ‘And, also, I feel that the case studies actually did help me, like, to prioritise my treatment … So, yes, for me it did play a role … .’

• ‘I feel the same; that it sets a baseline for you where you work from.’

Feedback

Feedback

• ‘We did the first one and then doctor … gave us corrections with the formats. ... Yes, the first one, I did nothing right.’

• ‘I think the critique and the way they worked with us, it really helped us.

I remember there was a case I had to do on Endo. I didn’t know anything about Endo ... and the process sticks in my mind because of the critique. If they were lenient I would probably go with my own way of thinking … the way they criticise, it is very beneficial for us … .’

OPB = Afrikaans abbreviation for comprehensive patient management (omvattende pasiëntbestuur).

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Table 2. Strategic recommendations made during focus group 1 • ‘ ... the very first patient that a fourth-year gets handed shouldn’t be a complex, complex case so that you feel lost … So, maybe if there can be some decent screening, seeing that this is a patient … not like a patient that needs a partial denture, an endo, four extractions … has, like, perio on six of the teeth ... If it is just a bit of an easier case, the first one, and then they can throw you into the deep end.’

• ‘But I think if they included pictures like in the beginning … it is nice to see stuff that you’ve seen before especially if you have to set up a treatment plan. So I think if they can include pictures in the third-year stuff, it will make stuff so much easier.’

• ‘So, if they give you, say, an example of what to do, say, on tooth 11 diagnosis, prognosis, those things, those things, next line … I mean, it will make stuff so much easier, it will make the marking for them easier and the students will be better off.’

• ‘Obviously, CPM includes Prosthetics with the treatment plan as you still have to, like at the end, maybe the patient will have to get partial dentures but he doesn’t get into details …, if they can include … and a detailed part of Prosthetics, then it will help a lot.’

• ‘I mean if we can actually get a subject like CPM for Ortho and for Prosthetics the performance will be so much better.’

• ‘ … they must try to maybe broaden everything.’

• ‘Yes, everything that we do in our fourth year we have to practise in our third year.’

• ‘I know that some of the students, when they did partial dentures, then they said you can still save the teeth and when they got to Prosthetics they told the patient, no, all the teeth have to be extracted, and then the patient has already been to five, six, seven, eight restorative sessions and then Prosthetics tells them, no, sorry, extract the teeth. So it is not really very nice for the patient, or for the students … so, if they can just have some correlation between them … because otherwise you get so confused … .’

• ‘You came into fourth year and you don’t have a clue of how the files work, where did the patient actually get the files and the payments. The patient asks me that all the time and I don’t have an idea.’

Table 3. Negative student feedback from focus group 2 about the value of the third-year case-based intervention in preparation for clinical teaching and learning Scaffolding • Comment 1: ‘For me, the assignments or the case studies did nothing really help … .’

• Comment 2: ‘The practical work that we’ve done on the buddies … did a good job for me, but the assignments ... ?’

• Comment 3: ‘I think I’m hard-headed when it came to the case studies. I think they are great for other people … but for me? I had issues with the case studies and assignments. I prefer practical and theory.’

• Comment 4: ‘I prefer modelling – it stays in my head – and a little bit of theory [rather] than case studies. I know case studies is the incorporation of it, but if I will rather act in it, than trying to figure out what somebody else is thinking … but when we come to practical and doing everything, it is good for me.’

• Comment 5: ‘ … when you get into fourth year and you see your first patient and you don’t know where you have to be, you don’t know what to do … and you are asking everybody and it [is] wasting a lot of time.’

• Comment 6: ‘But I feel it doesn’t actually teach us how to deal with difficult patients; like, I have the worst patient, like, I don’t know what to do because the patient was very angry because of the way he was treated and everything … so everything else was taken out on me ... , now, and I don’t know how to control the situation and then Dr Y had to step in.’

• Comment 7: ‘It is only with the third, fourth case studies it starts getting better, but the first one definitely not. If you go and look at your answers and look at someone else’s answers they were totally different. There wasn’t really a set way to answer anything. Yes, we were all confused about how to actually do the questions. So if there is a lecture before … we want this and this and this – whatever – then you will know better. Because everyone’s case studies look different and I was always confused about how to answer them.’

Data-processing ability • Comment 8: ‘So, for me, case studies, I don’t want to lie, even my maths are like, oh yeah, very low … .’

Diligence • Comment 9: ‘ … the case studies we did, did not really prepare us for that test we wrote at the end. There were questions that I had never thought about in my life before. Unless I did not complete the case studies properly? Or did not understand them well enough?’ (Translated from Afrikaans into English) Goal orientation • Comment 10: ‘Sometimes you don’t know how to prepare for it, like they say you have to go home and get this ready and do a slide show for this …

Sometimes it is a bit difficult to know what is expected of you to do … but otherwise it is okay.’

Unaware of learning opportunities • Comment 11: ‘So, we didn’t get feedback on any of the cases.’

• Comment 12: ‘Feedback. Yes, because we never got feedback on the case studies, and what was expected and what the students never saw. Because everything in a case study is said for a reason, and then just to know all the reasons, then you will know what to look for in that final test.’

• Comment 13: ‘Okay, I just remember we always got these pathology questions in the case studies that we were not always prepared for. They would say there is a white lesion in the back of your gums. How would you diagnose it, how would you treat it? We had no idea about pathology when we were in our third year … I always found those questions very difficult. I understand that we also should go and study or look up things but if we just had a bit of information … yes, if we were just a bit more prepared for it.’

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Research Focus group procedures

A dentist who was not directly involved with the intervention or with CPC, facilitated and voice recorded the focus groups discussion. To start the discussion, the facilitating dentist posed the following open-ended question to the students: ‘In terms of your own learning, how did you experience the case studies that were used in the third year of study to train your diagnostic- and treatment-planning skills?’

The facilitator allowed the students to respond randomly in a paticipative manner. Efforts were made not to lead the students in any way during the focus group session. However, the facilitator used probes for enquiring about how the students ‘experienced’ and ‘approached’ the case-based teaching and learning. When the session stagnated the students were questioned in a sequential order – as they were seated around the table – to respond to the facilitator’s questions. Eventually all students were afforded an opportunity to speak.

Transcription and analysis

An administrative member of staff of the School of Dentistry transcribed the voice data[23] into text format. The dentist who facilitated the focus groups controlled the transcription, made corrections, and also performed thematic analysis[24] of the data. The protocol allowed for themes to be gradually identified and added in an open-ended fashion.[22] The researcher controlled the thematic analysis after the initial identifi­ cation of themes by the facilitator of the focus groups. During this process, quotes from the discussion groups were reorganised by the researcher by merging themes with similar focus together into a single theme.[22] The quotes identified were tabulated per theme for both the sample groups.

Results

Only the focus group 1 discussion took place as originally scheduled. Focus group 2 had to be rescheduled.

Positive feedback regarding acquisition of prior knowledge in preparation for clinical teaching and learning through the preclinical case-based approach is reported in Table 1 for both focus groups. This feedback was thematically coded as follows: relevance; integration; scaffolding; and feedback.

Constructive feedback from focus group 1 to improve the teaching and learning in CPC is given in Table 2. These comments contain a variety of suggestions to improve the existing scaffolding strategies further. Similar suggestions were not obtained from focus group 2.

Comments generally relating to deficiencies in standardisation and calibration between faculty dominated the constructive feedback in focus group 2. One of these comments was: ‘So, yes, I think, just let the doctors be more on the same page.’

Negative perceptions, predominantly originating from focus group 2 about the case-based approach, are listed in Table 3. These results were thematically coded as follows: scaffolding; data-processing ability; diligence; goal orientation; unaware of learning opportunities; and attribution. In contrast to focus group 1, there were comments (Table 3) that suggest that the scaffolding (comments 1 - 7) was not adequate for all the students of the second focus group. The results from focus group 2 also suggest that some of the individual students may have had data-processing problems related to the complex case studies (comment 8) and 1 student admitted a lack of diligence (comment 9), while another indicated a lack of awareness of what was expected (comment 10). None of these themes was similarly evoked in

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focus group 1. Unlike the students from the first focus group, some students in group 2 did not know about the feedback given for each case study assignment (comments 11 and 12). Some of them were not aware of the introductory lecture that was given on pathological lesions in the third year of study (comments 13).

Discussion

This study sought feedback from fourth-year dental students regarding the value of the case-based interventions they were exposed to in the preclinical year of study. During the feedback process it was attempted to identify selfregulating behaviours[15,16] in those who progressed in clinical reasoning and self-handicapping behaviours,[17-20] in those who did not display progress.

The discovery of differences in self-regulation in clinical reasoning between progressing and non-progressing students may warrant the introduction of additional scaffolding and support for students lacking self-regulation in the educational intervention.

Focus group 1 (progression group) – interpretation of the feedback Students who improved their progress test scores over time thought that the third-year case-based intervention provided them with knowledge and skills that prepared them reasonbly well for the fourth year of study (Table 1). Positive remarks were made about the relevance of the teaching and learning, integration and the scaffolding of the transfer from the third to the fourth year of study.

The feedback provided in focus group 1 (Tables 1 and 2) can be interpreted as a positive appraisal of the preclinical case-based approach. Constructive suggestions were made to improve the educational processes – not only at CPC but also in the broader undergraduate curriculum. The students suggested the need for improved integration with disciplines such as prosthetics and orthodontics, standardisation, a need for clinical images in the supportive information and more knowledge about the administration of the hospital. These suggestions indicate the interest in the educational process and strategic thinking. The responses can also be interpreted as the students having a goal-orientated approach to providing improved care to their patients.[17] These observations are related to the forethought phase of the self-regulation cycle (Fig. 1).[17] The results suggest that the students may have reflected on aspects of the teaching and learning environment that could be improved so that they may improve their own clinical practice.

Focus group 2 (non-progression group) – interpretation of the feedback This group also made a substantial number of positive comments about the educational processes, which indicates some congruence with the attitudes and behaviours of the students in focus group 1. Issues raised about relevance, integration, scaffolding and feedback were similar to those raised by focus group 1.

Compared with the results of focus group 1, focus group 2 highlighted seve­ ral observations that could be related to self-handicapping behaviours.[19-22] The focus groups were advertised simultaneously to all parties concerned – verbally and in writing. Students from focus group 2 arrived late for the feedback session, while others did not arrive at all. Their excuse was that they could not find the unusual venue. The reasons for this behaviour remain speculative, but there appeared to be a lack of interest in the activity and a lack of proactive planning to ensure that they arrive on time.

Research Comments 5 and 10 (Table 3) hint towards a lack of strategic planning and suboptimal goal orientation (Fig. 1).[17,18] Comments 3, 4 and 7 suggest that some of the students may have lacked self-efficacy beliefs to meaningfully participate in the case study exercises. The students from this group (comments 11 - 13) were unaware of learning opportunities, which may also indicate absence or lack of interest during learning opportunities at the CPC unit. These observations relate to behaviours in the forethought phase of self-regulated learning and suggest that some students may have been lacking in task analysis and self-motivation beliefs (Fig. 1).[17,18] Comments 7 and 10 (Table 3) might, however, also indicate a lack inability of self-instruction, while comment 10 is an admission of one of the students of a lack of diligence, which may be compared with a lack of focus and attention.[17,18] A lack of diligence is defined as a form of selfhandicapping behaviour.[19-22] These observations relate to behaviours in the performance phase of self-regulated learning and suggest that some students may have been lacking self-control behaviours (Fig. 1).[17,18] Some of the negative comments may be interpreted as the students attributing their inability to perform to the inadequacies of the case-based approach. For example, they tended to blame their own inefficiencies on the instructional design (comments 6 and 9, Table 3) and a lack of feedback (comment 12). These observations imply inefficiencies in the self-reflection phase of self-regulated learning (Fig. 1) in this group.[17,18] The negative findings of this qualitative study show that the case-based intervention may still need refinement in terms of scaffolding, feedback and student support, and suggest that scaffolding and support should not only focus on the subject matter itself, but actively provide support aimed at developing the students’ self-regulating ability. Such an approach requires the early identification of students who display self-handicapping behaviours combined with appropriately designed feedback and tutor systems that could assist in the development of the students’ task analyses, motivational beliefs, performance and self-reflection abilities. This may also be applicable to other modules in the curriculum, but it might also be context specific.[25] The context of the current study is the development of clinical reasoning skills. It is pertinent to note that in terms of this study non-progressing students are not necessarily the ones who struggle to pass the course, but may be students with moderate or high marks.

Conclusion

The results of this study provide some evidence of qualitative differences in the feedback of students in terms of ‘self-regulated learning’ between those who showed progression in clinical reasoning and those who did not progress.

This study also suggests that the case-based intervention could further be improved by providing an additional scaffold to students who are at risk of not progressing in terms of their clinical reasoning ability. Faculty should therefore focus on the early identification of students who are unable to regulate their own learning, and the provision of timely feedback aimed at devloping self-regulation abilities.

Although the extent of the current study is small and limited to the performance of a single cohort of students, the findings may be valuable in paving the way for future similar research projects by linking actual performance to self-regulatory behaviour in an authentic teaching and learning environment.

Acknowledgement. Ms Barbara English of the Faculty of Health Sciences Research Office at the University of Pretoria is thanked for the language editing.

References 1. Postma TC. Evaluating the Impact of Adjunctive Integrated Case-based Dental Teaching and Learning on Clinical Reasoning in a Discipline-based Teaching and Learning Environment. PhD thesis. Pretoria: University of Pretoria, 2013:1-221.

2. Snyman WD, Ligthelm AJ. The new Pretoria curriculum. S Afr Dent J 2000;55(11):642-648.

3. University of Pretoria, School of Dentistry. The Pretoria BChD Qualification Competencies. Pretoria: University of Pretoria, 2008.

4. Seeliger JE, Snyman WD. A new approach to undergraduate dental education. S Afr Dent J 1996;51(12):746-749.

5. Postma TC, White JG. Developing clinical reasoning in the classroom – analysis of the 4C/ID-model. Eur J Dent Educ 2015;19(2):74-80. [http://dx.doi.org/10.1111/eje.12105] 6. Ashton S. Authenticity in adult learning. Int J Lifelong Educ 2010;29(1):3-19.

7. Biggs J. Enhancing teaching through constructive alignment. Higher Educ 1996;32:347-364.

8. Snyman WD, Kroon J. Vertical and horizontal integration of knowledge and skills − a working model. Eur J Dent Educ 2005;9(1):26-31.

9. Steinert Y, Snell LS. Interactive lecturing: Strategies for increasing participation in large group presentation. Med Teach 1999;21(1):37-42.

10. Harden RM, Davis MH. The continuum of problem-based learning. Med Teach 1998;20(4):317-322.

11. Wass V, van der Vleuten C, Shatzer J, Jones R. Assessment of clinical competence. Lancet 2001;357(9260):945949.

12. Norcini J, Anderson B, Bollela V, et al. Criteria for good assessment: Consensus statement and recommendations from the Ottawa 2010 Conference. Med Teach 2011;33(3):206-214. [http://dx.doi.org/10.3109/0142159X.2011.551559] 13. Kessner DM, Kalk CE, Singer J. Assessing health quality − the case for tracers. N Engl J Med 1973;288:189-194.

14. Darling MR, Daley TD. Oral pathology in the dental curriculum: A guide on what to teach. J Dent Educ 2006;70:355-360.

15. White JG, Kruger C, Snyman WD. Development and implementation of communication skills in dentistry: An example from South Africa. Eur J Dent Educ 2008;12(1):29-34. [http://dx.doi.org/10.1111/j.16000579.2007.00488.x] 16. White JG. Strategy for teaching communication skills in dentistry. S Afr Dent J 2010;65(6):260-265.

17. Zimmerman BJ. Investigating self-regulation and motivation: Historical background, methodological developments, and future prospects. Am Educ Res J 2008;45(1):166-183.

18. Zimmerman BJ, Campillo M. Motivating self-regulated problem solvers. In: Davidson JE, Sternberg RJ, eds. The nature of problem solving. New York: Cambridge University Press, 2003:239.

19. Ommundsen Y, Haugen R, Lund T. Academic self-concept, implicit theories of ability, and self-regulation strategies. Scand J Educ Res 2005;49(5):461-474.

20. Covington MV. Making the Grade: A Self-worth Perspective on Motivation and School Reform. New York: Cambridge University Press, 1992.

21. Urdan T, Midgley C. Academic self-handicapping: What we know, what more is there to learn? Educ Psychol Rev 2001;13:115-138.

22. Midgley C, Urdan T. Academic self-handicapping and achievement goals: A further examination. Contemp Educ Psychol 2001;26(1):61-75.

23. Gill P, Stewart K, Treasure E, Chadwick B. Methods of data collection in qualitative research: Interviews and focus groups. Br Dent J 2008;204(6):291-295. [http://dx.doi.org/10.1038/bdj.2008.192] 24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101.

25. Cleary TJ, Sandars J. Assessing self-regulatory processes during clinical skill performance: A pilot study. Med Teach 2011;33(7):e368-e374. [http://dx.doi.org/10.3109/0142159X.2011.577464]

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Research The meaning of being a pharmacist: Considering the professional identity development of first-year pharmacy students M van Huyssteen, PhD; A Bheekie, PhD School of Pharmacy, Faculty of Natural Science, University of the Western Cape, Bellville, South Africa Corresponding author: M van Huyssteen (mvanhuyssteen@uwc.ac.za)

Background. Professional identity underpins an individual’s perspective in the way they evaluate, learn and make sense of their professional practice.

In pharmacy education, the development of a professional identity has remained problematic, which may largely be attributed to the dearth of literature that properly defines, teaches and assesses professionalism.

Objectives. To identify and describe first-year pharmacy students’ professional identity and determine whether it changed during the first semester of the ‘Introduction to pharmacy’ course.

Methods. Students had to write three sequential reflective reports in which they were expected to identify critical experiences since their enrolment.

These served as reference points from which they could frame their sense of professional identity. After grading, each set of reports was ordered according to total marks allocated, of which every tenth report was selected for thematic analysis.

Results. Baseline reports indicated that students had a largely stereotypical view of the pharmacist as medicine supplier. Subsequent reports showed a shift in perspective, as students articulated a more complex role for the pharmacist, distinguished between the pharmacist’s role and that of other health professionals, and formulated the pharmacist’s positive value for society.

Conclusion. Our findings describe the attempts of first-year pharmacy students to internalise a professional identity during a first-semester module.

By applying concepts of social identity theory to sequential reflective assignments, an emerging professional identity could be interpreted, which was denoted by an increasing sense of belonging to the pharmacy profession.

Afr J Health Professions Educ 2015;7(2):208-211. DOI:10.7196/AJHPE.423

Professional identity underpins an individual’s perspective in the way they evaluate, learn and make sense of their professional practice.[1] Higher education institutions are being put under increasing pressure to prepare students for the world of work[1] by producing autonomous graduates who have the ability to make evidence-based decisions in line with their values in rapidly changing, complex and contradictory situations.[2] This requires practice-based curricula that contribute to the development of professional identities. Medical educators have therefore attempted to conceptualise professional identity development in terms of their teaching and learning contexts.[3-5] Social identity theory has been proposed and applied as one conceptual framework for the understanding of professional identity development, as it aims to define and explain the social and individual factors and processes that influence an individual’s sense of belonging to a specific social group, which encompasses professional groups.[3-7] In pharmacy education, the development of a professional identity has remained problematic, which may largely be attributed to the dearth of literature that properly defines, teaches and assesses professionalism.[8] A recent study among first- and third-year pharmacy students found that a professional identity is underpinned by a sound knowledge of basic science[9] instead of professional practice. Some postulate that the lack of pharmacy students’ socialisation into professional practice may be a reason for the so-called ‘crisis in professionalism’.[10] A recent systematic review of higher education literature revealed a general scarcity of articles that comprehensively define and explore the teaching and learning of professional identity development.[1] Nonetheless, the literature seems to agree on a two-pronged approach to underpin development of a

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professional identity during higher education: (i) it should enable student participation in experiences likely to be encountered in professional practice (also referred to as professional socialisation); and (ii) it should facilitate the student’s ability to make meaning[2] of these experiences through reflection and critical self-reflection.[1,2,11,12] The purpose of this enquiry was to identify and describe first-year pharmacy students’ professional identity and determine whether it changed during the first semester of the ‘Introduction to pharmacy’ course. In this article, sequential written assignments in the form of reflective critical incident reports were analysed. The structure of this article is as follows: firstly, some of the concepts of professional identity development are discussed, primarily in terms of social identity theory.[13] Secondly, the learning environment is contextualised in terms of the processes of socialisation and reflection. Lastly, the findings attempt to align students’ progressive descriptions of ‘what it means to be a pharmacist’ with concepts of social identity theory that charaterise the identity development process.

Professional identity formation and learning

According to the social identity theory, a person usually has a number of social identities [13] (e.g. gender, age, language, culture, socioeconomic class, personality type, occupation) that contribute to the construction of an allencompassing self-identity. Each social identity is contextualised in terms of the status of the specific social group (e.g. women, 30-something, Afrikaans, white, middle class, introvert, pharmacist) and power relationships in society,[14] which shape a social group’s stereotypical image (or ‘social title’). Through the cognitive process of self-categorisation, an individual may choose to identify with certain social groups.[3] This identification

Research process defines who a person is – the in-group (e.g. pharmacist) – as well as who a person is not – the out-group (e.g. doctor/nurse).

Group membership is usually associated with cultivating increasingly positive attitudes towards the in-group by appreciating its diversity and differentiating this diversity from out-groups.[3] The development of an in-group mentality is made accessible when an individual choosing to assume that social identity (e.g. pharmacist) participates in activities associated with the group (e.g. dispensing of medicine) or social engagements that require the salience of that social identity (e.g. advising patients about medicine). There is a natural tendency to link good attitudes to the in-group, resulting in the out-group being thought of as the opposite of the in-group (bad attitudes). These attitudes towards the out-group tend to have a homogenising effect in the mind of the individual, which gives rise to social stereotyping of this group.

The ‘development of a professional identity’ is primarily concerned with the process of integrating a new social identity into an indivi­ dual’s self-identity. The identity reconstruction process is dependent on the socialisation of an individual in appropriate roles and forms of participation in the community, and the ability to make meaning of socialisation encounters.[13] The aim of providing students with professional socialisation encounters (such as interacting with pharmacists, evaluating what they do, or actively seeking information about the profession[9]) is to increase the salience of professional identity, thus providing the opportunities to add personal meaning to the new social identity. This experience of the making of meaning allows students to construct their own ‘knowledge of ’ the profession as opposed to ‘knowledge about’ the profession (which they are taught in class).

By doing so, students are provided opportunities that might cultivate a sense of belonging to the professional group, as ‘one cannot develop a practice-centred identity simply by learning about the practice’.[10] The internalisation of a professional identity involves a change in what we know and how we know what we know. Thus, pharmacists may interpret their professional identity in different ways, as the process of internalisation is heavily dependent on a person’s ability to shape a coherent meaning.[15] Meaningmaking is limited by the level of complexity of an individual’s frame of reference (beliefs, feelings and values), which is dependent on cognitive, emotional and social aspects of self-identity.[15]

Therefore, the internalisation of a ‘new’ identity involves an increase in the complexity of an individual’s perspective or frame of reference.[12] The latter may become more complex if it is to be identified, analysed and challenged through critical reflection and self-reflection.[2] Initially, this process may manifest in students through feelings of discomfort, confusion and contradiction. It is important for them to be aware that feelings of discomfort are potential markers of a shift in identity[5] and for teachers to facilitate this understanding for students to drive their own growth.

Setting and structure of enquiry

The School of Pharmacy, University of the West­ ern Cape (UWC) launched its new curriculum in 2013, which included two pharmacy-focused modules for first-year students. This was the first time that staff from the School of Pharmacy had been involved in teaching first-year students.

This article focuses on the first-semester module entitled ‘Introduction to pharmacy’. The aim of this module was to announce the start of the journey in becoming a pharmacist, focusing specifically on the concept of ‘what it means to be a pharmacist’. Our enquiry was primarily explorative and descriptive in design. It comprised sequential reflective written assignments (Fig. 1), embedded within a continuum of didactic lectures providing explicit ‘knowledge about’ pharmacy and pharmacists, interspersed with socialisation encounters and group reflection.

Three sequential written assignments followed the structure of a reflective critical incident report.[11]

Written assignment 1

Socialisation 1

Group reflection

Each assignment consisted of a short narrative account of a critical experience identified by the student, interpreted as a significant learning moment, turning point or moment of realisation, which they thought contributed to their personal or professional identity development. The pur­ pose of the first assignment was to gauge the first-year students’ interpretations of ‘what it means to be a pharmacist’ before introducing the pharmacy curriculum and influence of lecturers (Fig. 1). This assignment served as a reference point from which later shifts in students’ descriptions could be determined.

The first socialisation component for the students was a service-learning experience at a primary school in an underserved community in Cape Town. The students were tasked to talk to groups of learners (Grades 4 - 7) for 1 hour, trying to establish what the learners knew about factors affecting their health. The service-learning experience was followed by a 2-hour group reflection on campus.[12] The purpose of group reflection was for students to share experiences that tended to be different or contradictory to their personal frame of reference (beliefs and morals about the world).

Contradictions between a personal frame of reference and real-world experiences may lower an individual’s self-esteem and thus threaten the professional identity development process.

Dialogue with different group members offers as many perspectives for the interpretation of the incident and eases the initial contradiction, affording a more inclusive interpretation of the experience. The second written assignment focused specifically on a critical incident that

Written assignment 2

Socialisation 2 and 3

Written assignment 3

Fig. 1. Sequence of investigation.

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Research enabled students to examine their self-identity and how their personal frame of reference correlated or did not correlate with their interpretation of their professional identity.

The second socialisation component was an interprofessional learning component completed at the Interdisciplinary Teaching and Learning Unit at UWC. It required students to participate in interprofessional group work (with students studying dentistry, occupational therapy, etc.) for 2 hours once a week over 7 weeks, and covered topics of health, social development and primary healthcare as part of their first-semester module.

The third socialisation component was an opportunity for students to attend a talk and engage with 3 guest pharmacists for ~1 hour, each practising in a different sector of pharmacy (industry, public primary healthcare and hospital (clinical) sector). These interactions aimed to expose students to a variety of potential role models and practice environments and it was hoped to reduce the perception of the stereotype pharmacist.[3] The three sequential written assignments formed part of the formative assessment mark for the module. Each assignment was graded according to a reflection rubric that included four main assessment criteria: clear and expressive description of the critical incident; analysis of how the incident contributed to the understanding of self, others and the profession; open, non-defensive self-appraisal of one’s own frame of reference; and language structure and use. Feedback on assignments focused on stimulating the students to re-examine their frame of reference relative to their experiences (on or off campus). The allocation of marks for each sequential assignment incrementally increased for the analysis and self-appraisal criteria and decreased for description and structure criteria to explore the depth of their critical analysis skills. The first and third assignments were marked by one individual assessor, but the second assignment was marked by three independent assessors using the reflection rubric. Inter-assessor variability should not have a marked effect on the findings of this investigation, as the grades of the students do not necessarily correlate with the strength of their professional identity. The grades were used as a tool to facilitate the sampling process. Each set of assignments (first, second and third) was ranked in order of the highest to the lowest score, of which every tenth assignment was sampled. Thematic analyses were done separately for each set of assignments.

Results and discussion

Findings are presented in the order in which the assignments were written.

The first set of assignments showed that students largely viewed the pharmacist as different from themselves and described critical incidents from the patient’s perspective. Students tended to describe the stereotypical role of the pharmacist, with most of the critical incidents relating to medicines.

Students’ perceived knowledge about ‘medicine’ was dominated by images of pharmacists dispensing it and advising people on how to administer it.

There were isolated examples of caring and professional conduct. Students tended to describe a pharmacist in terms of having scientific knowledge (mainly chemistry and biology) closely related to the requirements for being accepted into the pharmacy course, probably because this is what they had been exposed to. Students were not cognizant of the values of socialisation skills. These overwhelmingly stereotypical descriptions of the poorly communicating, independent and intelligent pharmacist were in line with findings from a previous interdisciplinary study conducted in the UK with neophyte undergraduate students (including audiologists, doctors, midwives, nurses, occupational therapists, pharmacists, physiotherapists,

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podiatrists, radiographers and social workers) who had to rate the professional attributes of different types of healthcare workers.[7] In another study from the UK, which compared the perception of professional identity between first- and third-year pharmacy students, the former tended to delay their identity development until they acquired a broad scientific knowledge.[9] The abovementioned findings reinforce the notion that early professional identity development during pharmacy education is particularly weak. This is hardly surprising, as the students are mainly exposed to the natural sciences at the School of Pharmacy rather than professional practice during their first year.

After the first socialisation encounter, the second set of assignments described students’ first experiences of ‘being’ a pharmacy student. One student noted that ‘I felt appreciated and important’. Another student described this in terms of her feeling of belonging to the profession: ‘As pharmacy students we were wearing our lab coats and lanyard as to respect and represent the pharmacy job, so that even the learners can see we did not send ourselves, but we have been sent.’ The previous two quotes described students’ experiences of ‘being perceived as’ pharmacy students rather than ‘being’ pharmacy students. This is not surprising, as they have had little exposure to the pharmacy practice setting. Other students described experiences with a more internal focus of their engagements with others.

This was evident from some students expressing their feelings of unease at the new responsibility that went with ‘being’ a pharmacy student: ‘These children were letting me into their lives and it was up to me to listen and practise confidentiality with the important information that they had rendered on my shoulders.’ By making some of the roles of the pharmacist accessible, students could start identifying qualities of a pharmacist, such as empathy, adaptability, compassion and humility, on the basis of personal experience and not only from what they were taught in class. Students realised that the role of the pharmacist did not only require (stereotypical) knowledge and skills, but demanded personal maturity and the development of self-responsibility. This realisation seemed to add value to and respect for the role of the pharmacist in society, as illustrated below: ‘The reason why this incident had this effect on me I think it’s because I did not know that becoming a pharmacist was all about care taking and making a great change in someone’s life not by just dispensing medicine but also helping them by giving them advice and because I had little knowledge before going to that school but now I am no more in that nut shell.’

In the third set of assignments some students started to express their perceptions of the undervalued role of the pharmacist in society. With regard to identity development, this may suggest that students were starting to identify with pharmacists as the in-group by delineating professional boundaries with out-groups, as noted in the following: ‘The doctor is the custodian of diagnosis and the pharmacist the custodian of medicines.’

Furthermore, students reported a broader and deeper understanding of the role of the pharmacist. They valued the core competencies that pharmacists were required to attain when handling medicines, i.e. discovery and design of new products and industry-linked activities such as manufacture, storage and distribution of bulk supplies. They also seemed to articulate the attributes that a good pharmacist should have, e.g. communication as an especially valuable skill. Students expressed their desire to be more engaging/patient-centred and asserted to fulfil this role in future.

Furthermore, they commented on the personal growth they experienced during this course: ‘Not only have I learnt so much about the pharmacy

Research profession but I have come to know many things about myself that I was unaware of.’ This is especially important, because a complex frame of reference, usually associated with maturity, is important for the reflective ability needed to develop a strong professional identity. [2,5,15] Limitations of this enquiry include that the results were based on selfreport and linked to a mark for formative assessment, which might have made the students identify with a pharmacist more positively than was the case. Another limitation might have been that students’ professional socialisation encounters did not occur in a pharmacy and were not facilitated by a pharmacist, i.e. an atypical practice environment. This environment may have diluted the experience of a pharmacist identity in favour of a more generic healthcare worker identity (non-traditional pharmacist identity). However, this is a common problem in pharmacy education, where some educators perceive the role of the pharmacist to be more ‘traditional’, while others recognise the need of being a more active participant and decision-maker in the healthcare team and with the patient.[8] This distinction is important because it seems to be the cause of the ‘realistic disenchantment’ that some pharmacy students experience during the latter years of study, when confronted with the gap between theory and practice.[8]

Conclusion

Our findings describe first-year pharmacy students’ attempts to internalise a professional identity during a first-semester module. By applying concepts of social identity theory to sequential reflective assignments, an emerging professional identity could be interpreted, which was denoted by an increasing sense of belonging to the pharmacy profession. It is recommended that studies on professional identity continue to track the development of identity over the undergraduate period, as ongoing inconsistencies may develop between

theory and practice – the traditional role of the pharmacist being increasingly assumed by the student. The idea of an evolving identity is in line with a more general assumption in higher education, i.e. that ‘Educators must now design curricula that will help graduates engage with a constantly shifting professional identity. Rather than help build armour that they can then face the world and their clients with over the course of their career, educators must now help students to see that they are constantly becoming professionals and that their identity development is increasingly fluid.’[1] References 1. Trede F, Macklin R, Bridges D. Professional identity development: A review of the higher education literature.

Studies in Higher Education 2012;37(3):365-384. [http://dx.doi.org/10.1080/03075079.2010.521237] 2. Lewis P, Forsythe GB, Sweeney P, et al. Identity development during the college years: Findings from the West Point longitudinal study. Journal of College Student Development 2005;46(4):357-373. [http://dx.doi. org/10.1353/csd.2005.0037] 3. Burford B. Group processes in medical education: Learning from social identity theory. Med Educ 2012;46:143152. [http://dx.doi.org/10.1111/j.1365-2923.2011.04099.x] 4. Goldie J. The formation of professional identity in medical students: Considerations for educators. Med Teach 2012;34:e641-e648. [http://dx.doi.org/10.3109/0142159X.2012.687476] 5. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: Integrating identity formation into the medical education discourse. Acad Med 2012;87(9):1185-1190. [http://dx.doi.org/10.1097/ACM.0b013e3182604968] 6. Adams K, Hean S, Sturgis P, et al. Investigating the factors influencing professional identity of first year health and social care students. Learning in Health and Social Care 2006;5(2):55-68.

7. Hean S, Macleod Clark J, Adams K, et al. Will opposites attract? Similarities and differences in students’ perceptions of the stereotype profiles of other health and social care professional groups. Journal of Interprofessional Care 2006;20(2):1-20. [http://dx.doi.org/10.1080/13561820600646546] 8. Rutter PM, Duncan G. Can professionalism be measured? Evidence from the pharmacy literature. Pharmacy Practice 2010;8(1):18-28.

9. Taylor KMG, Harding G. The pharmacy degree: The student experience of professional training. Pharmacy Education 2007;7(1):83-88. [http://dx.doi.org/10.1080/15602210601149383] 10. Duncan-Hewitt W, Austin Z. Pharmacy schools as expert communities of practice? A proposal to radically restructure pharmacy education to optimize learning. Am J Pharmaceutical Educ 2005;69(3):370-380.

11. Branch WT. Use of critical incident reports in medical education. J Gen Intern Med 2005;20:1063-1067.

12. Mezirow J. An overview on transformative learning. In: Illeris K, ed. Contemporary Theories of Learning: Learning Theorists … in Their Own Words. New York: Routledge, 2009:90-105.

13. Tajfel H. Human Groups and Social Categories: Studies in Social Psychology. Cambridge: Cambridge University Press, 1981:1-369.

14. Hogg MA, Abrams D. Social Identitifications: A Social Psychology of Intergroup Relations and Group Processes.

London: Routledge, 1998:1-268.

15. Kegan R. In Over Our Heads: The Mental Demands of Modern Life. Massachusetts: Harvard University Press, 1994:1-396.

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Research Field trips as an intervention to enhance pharmacy students’ positive perception of a management module in their final year: A pilot study M J Eksteen, MPharm; G M Reitsma, PhD Africa Unit for Transdisciplinary Health Research (AUTHeR), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa Corresponding author: M J Eksteen (mariet.eksteen@nwu.ac.za)

Background. Management training is an important aspect of pharmacy training, as many pharmacists are appointed in management positions early in their careers. However, students struggle to see the importance and relevance of a management module in the final year of the BPharm curriculum and show low levels of motivation and engagement with regard to the module. A possible strategy to change students’ perceptions of the importance of a management module is the inclusion of field trips in the curriculum.

Objective. To determine whether students’ experience of field trips influenced their perceptions regarding a management module as part of their training as future pharmacists.

Methods. A mixed-method sequential exploratory research design was used. Data were gathered through written narratives and focus group interviews, followed by surveys before and after the field trips.

Results. The students who participated in the field trips (experimental group) had higher mean scores in the post-test than those who did not participate (control group). The experimental group was more positive about the module than the control group. The field trips improved the perception of students regarding the importance of the management module for future job preparation.

Conclusion. Field trips add value to pharmacy training and should form part of the BPharm curriculum in South Africa.

Afr J Health Professions Educ 2015;7(2):212-215. DOI:10.7196/AJHPE.436

The training of pharmacy students in South Africa (SA) takes place through an intensive 4-year programme. There are 5 major subject groups in the Baccalaureus Pharmaciae (BPharm) curriculum: Pharmacology, Pharmaceutics, Pharmaceutical Chemistry, Clinical Pharmacy and Phar­ macy Practice.[1] Pharmacy Practice comprises 7 modules related to the practice of a pharmacist, which includes the patient, medicine distribution, health management and good pharmacy practice, communication, financial management, managed healthcare and general management and human resource management. The last-mentioned module was the context for this study. Students’ lack of engagement in introductory management modules, especially non-major modules, is a common phenomenon.[2] This was also the case for an introductory management module for pharmacy students. Students tend to be negative about the module if they do not perceive the work as valuable or important for their development as future pharmacists.

Although the Exit Level Outcomes are prescribed by the South African Qualifications Authority (SAQA),[3] most students have difficulty integrating the theory of management with pharmacy practice. It seems as if they do not see the bigger picture and have difficulty understanding where/ how management fits into their everyday life and professional careers.

Students don’t realise that pharmacists will very likely be appointed as pharmacy managers about 2 years after graduation owing to the shortage of pharmacists in SA.[4] A possible strategy to influence students’ understanding and perception of the importance of a management module is the inclusion of field trips in the curriculum. When planned efficiently, field trips add additional value to and enrich the classroom.[5] Such trips can contribute to and complement the textbook used during formal class lectures[6] and even present better learning outcomes than school-based learning.[7]

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Such trips assist students in the development of ideas and a deeper understanding around the field/profession and prevent the straightforward memorisation of facts.[6,7] Field trips enhance students’ awareness on a cognitive and an affective level,[8] which often cannot be achieved in the classroom.[9] Cognitive learning is achieved when students can make connections among and interpret different aspects of a subject to apply what they have learned in other fields of practice or the profession.[7] Field trips also result in increased memory.[8] From the literature reviewed, field trips are commonly included in subjects such as geography and museum studies,[5-9] biology and ecology[10] and law.[11] In this study, we used field trips as a strategy to influence students’ perceptions regarding a management module as part of their training as future pharmacists. The aim of this article is to report, for the first time, on the findings of a research study on the implementation of field trips in a management module in the BPharm curriculum and to conclude whether this intervention changed pharmacy students’ perception of the module.

Method

A mixed-method sequential exploratory research design was followed, where qualitative data were first gathered to explore students’ perceptions of the management module. Quantitative data were then gathered to measure the effect of the field trips on the students’ perceptions.[12-14] The qual/quant approach started with written narratives, followed by in-depth focus group interviews and a survey (pre-post questionnaire). The purpose of the study, voluntary participation and anonymous handling of data were explained to students before informed written consent was received. An independent researcher in higher education teaching and learning facilitated the datagathering process to ensure anonymity. The North-West University ethics committee granted permission for the study to be done.

Research Written narratives

The first phase of the research included all students who attended the specific management module (n=156) and wrote 1-page qualitative narratives reflecting on the importance and relevance of this module and their expectations of it. The content was analysed to determine trends and patterns,[15] from which specific themes were identified for further investigation through focus group interviews. Credibility of this qualitative method was ensured by requesting all students in the class to write the narratives, thus increasing the scope of feedback, providing a safe place and time for students to write anonymous reflections, and explaining the purpose of the process clearly.[16]

Focus group interviews

The second qualitative phase consisted of focus group interviews with the 32 ‘branch managers’ in the class. (All the students who were enrolled for this module formed different groups, referred to as branches, and each group had to appoint a branch manager.) The purpose of the focus group interviews was to explore the themes raised in the written narratives. The independent researcher transcribed the interviews to ensure anonymity, thus conforming to ethical conduct. The transcribed interviews were then analysed[17] through a process of identifying, analysing and reporting patterns in the data.[18] Trustworthiness of the qualitative data was ensured by the engagement of the researchers in the field of research for an extended time (at least one semester) and by applying triangulation[12] by using different methods and different data sources to investigate the same phenomena. The data from the narratives were analysed and the themes were used to inform the focus group questions. The written narratives and transcribed focus group interviews were presented as evidence that the findings were from the data and not the ideas or preferences of the researchers, thus ensuring confirmability (neutrality or objectivity).[19]

Pretest survey

The third phase of research started with a pretest questionnaire. The purpose of the questionnaire was to determine the students’ perceptions of the relevance of this module to their current training and their employment after graduation. The questionnaire was compiled based on data gathered from the focus group discussions. Content validity was ensured by formulating the questions from the focus group data. Face validity was ensured by presenting the draft questionnaire to an independent educational researcher and a statistician to evaluate and refine the questionnaire. Nine statements regarding the relevance of the module to practice were formulated. Students had to indicate, on a scale of 1 - 5, their level of agreement with these statements: 1 – do not agree at all, and 5 – agree totally. The quantitative data were analysed using descriptive statistics, e.g. mean and standard deviation (Table 1) and independent samples t-test and Cohen’s d-value.

Population and sample for the survey

One of the major obstacles in planning a field trip is funding.[21] Because this was a pilot study, the sample was limited to a manageable group within the scope of available time and money. The sample was large enough to provide useful information regarding tendencies in the group that can be investigated in future larger-scale studies. A simple random sample (20.6%, n=34) of the total number of students who enrolled for the module (N=165) was selected and invited to attend the three field trips. Participation was voluntary and 9 students withdrew. The final experimental group comprised

25 students. The selected students were briefed on what would be required of them during the field trips, the required commitment of attending all three field trips, logistical aspects such as transport and food,[22] and the guarantee that their participation in or withdrawal from this project will in no way influence their marks for the module. Those who did not participate in the field trips formed the control group (n=140).

Field trips

The main purpose of the field trips was to expose the experimental group to a diversity of real-life scenarios, where the same management principles discussed in theory were applied in the different sectors of the pharmacy profession. The first field trip focused on pharmacists’ experience as managers. Students interacted with guest speakers from academia, the corporate pharmacy community and the government sector. The second field trip was a visit to a large corporate pharmacy with different divisions, e.g. an independent community pharmacy, a wholesaler, courier pharmacy and training academy for pharmacy assistants. The third field trip was an excursion to a mining hospital pharmacy chain group.

Post-test survey

After the intervention, the experimental and control groups completed a post-test questionnaire similar to the pretest one.

Results

The themes identified from the written narratives included the following: place and value of the management module in the curriculum; students’ opinions on the content of the module; possible reasons why students experience this module as a waste of time, their perception being that it is time costly with regard to more important modules; and importance of practical experiences for the students. During the focus group interviews, these themes were further explored and clarified.

Initially, students did not see or understand the importance of the module for their future professional careers. This was evident from comments made during the focus group interviews, such as, ‘I don’t think we see the value of this module, we have to take it, so we just have to deal with it’, and ‘They don’t see this as important because of their mind set’. Students were negative about this module, because ‘... anything other than pharmacology is a waste of time’. This concurs with Taylor et al.’s[2] research findings on non-major management modules.

The results of the pre- and post-tests are presented in Table 1. Questions 1 - 3 measured students’ perception of the relevance of the management module to practice. The results indicated that the students were positive about the relevance in both the pre- and post-tests. However, there was a slight decrease in the control group’s perception in the post-test. Questions 4 and 5 determined whether students were able to link their own practical experience to the module content and whether they needed more practical exposure. Both the experimental and control groups’ agreement decreased slightly in the post-test compared with the pretest. The experimental group, however, felt more strongly in the post-test (d=0.26) that they did not see the need for more exposure to practise compared with the control group, where no practical significant difference was measured between the pre- and posttests for this statement. Questions 6 - 9 measured the students’ perceptions of how this module prepares them for their future as pharmacists. There was a definite improvement in the experimental group’s perceptions of the value of the module for their future employment, with medium practical

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Research

Table 1. Responses of the experimental and control groups regarding relevance of the module to practice before and after the field trips (pre- and post-test) Post-test, mean (SD)

Effect size t-test between groups E and C for posttest (d-value)† 0.05

Survey questions

Group

Pretest, mean (SD)

Q1: T his module would have been of more use to me if I had completed it before I did my practical hours in a pharmacy

E

2.80 (1.0)

3.00 (1.2)

C

2.9 (1.1)

3.06 (1.2)

Q2:* A ccording to me, the theoretical content of this module is not related to practice

E

1.52 (0.5)

1.60 (1.0)

C

1.70 (0.7)

1.74 (0.8)

E

1.48 (0.6)

1.48 (0.7)

C

1.80 (0.9)

1.74 (0.9)

Q4: I easily understand the work in the module because I can think of practical examples for most of the concepts

E

4.16 (0.6)

4.00 (0.9)

C

4.01 (0.8)

3.86 (0.9)

Q5:* It isn’t really necessary to add more practical exposure to this module

E

2.16 (0.9)

2.48 (1.2)

C

2.53 (1.1)

2.56 (1.1)

E

4.60 (0.5)

4.68 (0.6)

Q3:* The module content is completely unrelated to practice

Q6: I see this module as useful to me as prospective pharmacist

C

4.42 (0.6)

4.22 (0.8)

Q7: T he knowledge and skills that I am learning in this module are what I will need one day in my job

E

4.44 (0.7)

4.56 (0.8)

C

4.21 (0.7)

4.04 (0.8)

Q8: To some degree I can understand how this module will help me some day in practice

E

4.4 (0.5)

4.36 (0.6)

C

4.17 (0.7)

4.10 (0.8)

E

1.88 (1.1)

1.52 (0.6)

C

1.73 (0.8)

1.95 (1.0)

Q9:* I can’t really see how the knowledge and skills in this module are necessary for my job one day

0.14 0.28 0.15 0.06 0.59 0.62 0.33 0.42

E = experimental group (n=25); C = control group (pretest, n=128; post-test, n=108). * Questions asked in a negative trend. † An effect size of 0.2 is small, 0.5 medium and 0.8 large.[20]

significance measured in Question 6 (d=0.59) and Question 7 (d=0.62).

Questions 2, 3, 5 and 9 were stated in a negative sense; therefore, the low means indicate that the students did not agree with the negative statement.

Discussion

The impact of an intervention in the form of field trips on student perceptions was researched through an exploratory mixed-method approach. By increasing student engagement through field trips, the researchers aimed to influence students’ perceptions regarding the value and importance of the module. Evidence from the quantitative phase indicated that these field trips did have a positive impact on students’ perceptions. Contrary to the findings from the focus groups, the students as a class were not as negative about the management module as first perceived, as is evident from the higher than average pretest means for the experimental and control groups (Table 1).

The effect sizes indicated no significant difference between the experimental and control groups in the pretest.

In the post-test, the mean scores for the experimental group increased for most of the items, indicating a more positive perception of the module.

However, the control group’s responses were more negative in the post-test, indicating that they still did not understand the value of the module in preparing them for their future positions. This may be because few students had to apply management knowledge and skills in their previous practical work. They explained this as follows: ‘The younger you are, the less you do in the pharmacy. First you only wash shelves and it is only in your third year that you start with dispensing’ and ‘They [the pharmacy staff] don’t really give you more to do’. Students may have difficulty linking the concepts

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addressed in the module to practical examples owing to limited exposure to practice.

The means of all the questions in the pretest for the experimental and control groups indicate that there was already a positive expectancy towards the importance of this module in the BPharm curriculum before the intervention. This was in contrast to what the lecturer perceived at the beginning of the semester with regard to student comments.

Overall, the means for the experimental group were higher than those for the control group, although the difference was only practically significant for Questions 6 and 7. The field trips as intervention did contribute to the experimental group having a better understanding of the importance of this module towards their future roles as pharmacists. The experimental group better understood that the knowledge and skills taught in this module are important for their future employment. Understanding the significance of what they learn, may influence their perceptions positively. Marzano[23] explained the importance of assisting students to develop positive attitudes and perceptions about learning, without which they have little chance of learning proficiently, if at all. If students have certain attitudes and perceptions, they have a mental climate conducive to learning. If those attitudes and perceptions do not exist, learners have a mental climate not conducive to learning.

Conclusion

Students’ negative perception of introductory non-major management modules is a common phenomenon at universities. In this study, field trips were implemented as an intervention to determine whether students’

Research experience of field trips influence their perceptions regarding a management module as part of their training as future pharmacists. This was motivated by the comments made by students and confirmed during analysis of written narratives and focus group interviews. The survey results showed that the field trips did not have a practically significant effect on students’ overall positive perception of the relevance of this module to practice. This may have been because of high mean scores measured in the pretest, indicating that students were already positive about the module and its relevance to practice. It is, nonetheless, evident that students who did not participate in the field trips did not show the same positive perception of the module as those who did partake in the trips, as there was a clear tendency towards higher mean scores in the post-test results of the experimental group. The field trips influenced students’ perceptions of the importance of the module for their future positions. Therefore, it can be concluded that field trips in the management module in the BPharm curriculum changed students’ perception positively towards this module.

Although the quantitative study did not statistically prove the positive impact of field trips on all the concepts measured, the experimental group gained more from this experience than those students who did not participate in the field trips. Field trips may have a positive effect on student perception and it is recommended that such trips should be included in the teaching-learning repertoire of modules in the pharmacy curriculum to expose students to relevant practices.

Furthermore, this study indicated that student comments and conversations may provide important information regarding teaching and learning that should be taken into consideration in planning and presenting modules. Student voices on teaching-learning aspects may provide useful and critical information for lecturers to improve their teaching. Lecturers should include more opportunities for conversations through focus group discussions or reflective narrative writing to gain insight into student experiences.

The researchers acknowledge that including only a small sample of the students from the same class for the field trips may be a limitation to the

study. As there was lack of funding, not all students were invited to attend the field trips. Also, possible ‘contamination’ could have taken place as the experimental and control groups were students from the same class and informal discussions could have taken place between students discussing the field trips and their experience thereof.

References 1. North-West University. Yearbook of the Faculty of Health Sciences, Undergraduate. Potchefstroom: North-West University, 2014.

2. Taylor SA, Hunter GL, Melton H, Goodwin SA. Student engagement and marketing classes. Journal of Marketing Education 2011;33(1):73-92. [http://dx.doi.org/10.1177/0273475310392542] 3. South African Qualifications Authority. Registered Qualification: Bachelor of Pharmacy. Pretoria: SAQA, 2011. http://regqs.saqa.org.za/viewQualifications.php?id=72784 (accessed 11 February 2014).

4. South African Pharmacy Council. Pharmacy Human Resources in South Africa. Pretoria: South African Pharmacy Council, 2011.

5. Sturm H, Bogner FX. Learning at workstations in two different environments: A museum and a classroom.

Studies in Educational Evaluation 2010;36(1):14-19. [http://dx.doi.org/10.1016/j.stueduc.2010.09.002] 6. Demirkaya H, Atayeter Y. A study on the experiences of university lecturers and students in the geography field trip. Procedia Social and Behavioural Sciences 2011;19:453-461. [http://dx.doi.org/10.1016.j.sbsp ro.2011.05.154] 7. Gill N, Adams M, Eriksen C. Engaging with the (un)familiar: Field teaching in a multi-campus teaching environment. J Geogr Higher Educ 2012;26(2):259-275. [http://dx.doi.org/10.1080/03098265.2011.619523] 8. Falk JH, Dierking LD. School field trips: Assessing their long-term impact. Curator 1997;40(3):211-218.

9. Sanders M. Planning a fieldtrip to the Cradle of Humankind: A model of factors affecting the success of educational museum visits. 18th Annual Meeting of the South African Assosiation for Research in Mathematics, Science and Technology Education, 18 - 21 January 2010, Durban, South Africa. http://www.saarmste.org/ conferences (accessed 10 February 2014).

10. Lei SA. Field trips in college biology and ecology courses: Revisiting benefits and drawbacks. J Instruct Psychol 2010;37(1):42-48.

11. Higgins N, Dewhurst E, Watkins L. Field trips as teaching tools in the law curriculum. Research in Education 2012;88:102-106.

12. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 2nd ed. California: Sage, 2011.

13. Macmillan J, Schumacher S. Research in Education. Evidence-Based Inquiry. New York: Pearson, 2014.

14. Drew CJ, Hardman ML, Hosp JL. Designing and Conducting Research in Education. Los Angeles: Sage, 2008.

15. Mayring P. Qualitative Content Analysis. Forum: Qualitative Social Research, 2000. http://www.qualitativeresearch.net/index.php/fqs/article/view/1089/2385 (accessed 15 April 2014).

16. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105-112. [http://dx.doi.org/10.1016/j.nedt.2003.10.001] 17. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci 2013;15:398-405. [http://dx.doi.org/10.1111/nhs.12048] 18. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3(2):77-101. [http://dx.doi.org/10.1191/1478088706qp063oa] 19. Tobin GA, Begley MC. Methodological rigour within a qualitative framework. J Adv Nurs 2004;48(4):388-396.

20. Cohen J. A power primer. Psychol Bull 1992;112(1):155-159.

21. Anderson D, Kisiel J, Storksdieck M. Understanding teachers’ perspectives on field trips: Discovering common ground in three countries. Curator 2006;49:365-386.

22. Kent M, Gilbertson DD, Hunt CO. Fieldwork in geography teaching: A critical review of the literature and approaches. J Geogr Higher Educ 1997;21(3):313-332.

23. Marzano RJ. A Different Kind of Classroom: Teaching with Dimensions of Learning. Alexandria, VA: Association for Supervision and Curriculum Development, 1992.

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Research An exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a South African university J R Naidoo,1 B Nursing, M Nursing (Nursing Research), PhD Nursing; S Mthembu,2 B Nursing, M Nursing (Nursing Education), PhD Nursing Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

1 2

KwaZulu-Natal College of Nursing, Pietermaritzburg, South Africa

Corresponding author: J R Naidoo (naidoojr@ukzn.ac.za)

Background. The global landscape of higher education has repositioned itself, moving away from insular institutions towards open responsive systems of teaching and learning with an emphasis on cultivating a new mode of knowledge production. The South African higher education system has responded to these global changes by recognising the contribution of research productivity as a commodity within the overall worldwide knowledge economy. These changes have contributed towards an increased intake of candidates in many university faculties, including nursing, to meet the demand of producing highly skilled graduates.

Objectives. To explore and describe the current practices and experiences of nurse academics regarding postgraduate research supervision.

Methods. A descriptive exploratory design with in-depth interviews was used, and a self-reported questionnaire eliciting information on research supervision practices.

Results. Three emergent themes were identified from the results of this study: a lack of standardised guidelines for nurse academics to effectively supervise postgraduate research; the pressure that nurse academics experience regarding postgraduate research supervision; other demanding roles of an academic, such as a high teaching and clinical workload.

Conclusion. The study demonstrated gaps in research supervision, shared frustrations such as feelings of isolation, and a lack of support systems.

Afr J Health Professions Educ 2015;7(2):216-219. DOI:10.7196/AJHPE.443

The discourse on the nature of research supervision in higher education institutions has received much attention.[1] Changes in the economic, political and workplace arenas of many developing countries have highlighted the contribution of research in higher education programmes towards a skilled workforce and in the overall global knowledge economy.[2] The higher education landscape in the South African (SA) context has not been exempt from these changes; many faculties, such as nursing, have increased the number of students accepted into their postgraduate programmes to respond to the demand of producing highly skilled graduates.[3-5] In the selected university, the Department of Nursing has seen an increase in the number of postgraduate students – from approximately 120 students in 2009 - 2010 to 207 in 2011 - 2012 (College of Health Sciences Postgraduate and Research Annual Report, University of KwaZulu-Natal, 2013).

The selected Department of Nursing has 17 academic staff, 12 of whom are involved in postgraduate supervision. Given the increased intake of postgraduate students, the central issue confronting research supervisors concerns how academics can achieve quality postgraduate research supervision and accelerate graduate throughput rates.[6,7] Research supervisors at higher education institutions are increasingly challenged to facilitate the learning of postgraduate students from diverse backgrounds by innovative and progressive research supervision methods.[2] Furthermore, postgraduate research supervision is increas­ ingly seen as a teaching and learning construct that fosters deep learning and critical inquiry.[1] It therefore demands that academics be continuously trained with innovative methods to harness and

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develop this skill in postgraduate research supervision.[2,7] The latter is considered to be multifaceted, challenging academics to master the skill of facilitating learning and creating the supervision experience as a social learning construct for the student, coupled with supervising an increased number of postgraduate students.[4,7-9] The aim of this study was to explore the experiences and practices of nurse academics with regard to postgraduate research supervision.

Methods Design

A descriptive exploratory design underpinned the study. This design was considered appropriate to elicit the experiences and overall practice of the nurse academics regarding postgraduate research supervision. In-depth individual interviews were conducted with key informants – the nurse academics involved in postgraduate research supervision.

Setting and sample

The selected Department of Nursing offers a postgraduate programme: a Master’s in Nursing (either coursework or fulltime research) and a PhD in Nursing (research only). There were 12 academics involved in postgraduate research supervision at the time of the study. Given the small target population, non-probability purposive sampling was used. All academics had a minimum of at least 12 months and a maximum of 13 years postgraduate research supervision experience. The heterogeneity in the years of experience enhanced the shared experiences.

Research

Data gathering and analysis

Each individual in-depth interview lasted 45 - 60 minutes and was guided by probing questions, which focused on eliciting the overall experiences and practices of postgraduate research supervision. The interviews were audio-recorded, transcribed and saved in MS Word on a password-protected laptop. Thematic analysis was used to identify emergent themes. A self-reported questionnaire eliciting information on postgraduate research supervision practices was also administered to each participant before the interview and was reported using percentages and frequency counts. The questionnaire focused on the mode of supervision, years of experience involved in research supervision, use of supervision contracts and models, and number of postgraduate students being supervised. The probing questions of the individual in-depth interview and the items of the self-reported questionnaire were informed by literature related to postgraduate research supervision.

Ethical considerations

After institutional ethical approval (HSS/0777/013), departmental permission was granted by the Dean and Head of the School. A letter stating the purpose of the study and detailing its nature was distributed to all participants, who were advised that they could withdraw from the study at any time without reason and that their participation was voluntary and had no bearing on their current positions in the Department of Nursing. There were no direct benefits to the study participants; however, the study results will have an aggregate benefit to the wider nursing department in terms of providing insight into the experiences and practices of research supervision. Anonymity was maintained throughout data collection. No identifying information was requested from the participants. While the researcher was also an academic involved in postgraduate research supervision, the researcher bracketed and did not include her feelings, views and experiences of postgraduate research supervision from the collected data. The second researcher, with whom the main researcher reflected after the individual interviews, facilitated bracketing.

Trustworthiness

Table 1. Sample characteristics Variable

Mean

Range

Length of time as an academic (years)

6.2

3 - 12

Length of time supervising (years)

4.7

2 - 10

Master’s students being supervised at time of interview, n

7

2 - 12

Students graduated, n

1

0-6

Length of time per week supervising (hours)

8.5

3 - 10

Sessions per month with each student, n

2

2-4

Length of time per supervision session (hours)

1.5

1 - 2.5

Experiences of postgraduate supervision (Table 2)

Three prominent themes emerged during data analysis: (i) overwhelmed and frustrated; (ii) pressure to perform; and (iii) getting the balance right.

Table 2. Postgraduate research supervision practices Yes, n (%)

No, n (%)

Contact (face to face)

7 (100)

-

Email correspondence

7 (100)

-

Skype/video-conferencing or related mode

2 (29)

5 (71)

Other: cohort/group

1 (14)

6 (86)

Use of a supervision contract

5 (71)

2 (29)

Use of models of supervision

1 (14)

6 (86)

Variable Mode of supervision

Results

Overwhelmed and frustrated Most participants experienced research supervision as an overwhelming task, expressing feelings of fear and loss of confidence as an academic when they initially started supervising. Moreover, participants noted that they experienced a loss of control in managing their role as an academic, which they largely perceived as being focused on teaching and learning activities. Participants who were less experienced with postgraduate research supervision reported feeling fearful with the expectation of accelerated graduate throughput.

They further noted that they experienced the challenge of trying to meet the expectation of successful and quality postgraduate research supervision without clear guidelines to facilitate successful supervision: ‘When I started I was given students to start supervision … I didn’t know where to begin … there was nothing to guide me … no guidebooks ... .’ ‘ … I felt scared … not knowing what was research supervision and how to start doing this, and at the same time we are expected to have high completion rates … .’

‘We are told about making sure our research students complete and graduate in the time given … one becomes afraid especially because some of us have not supervised masters students before.’

Data saturation occurred after individual in-depth interviews with 7 parti­ci­ pants. Table 1 presents a descriptive summary of the participants’ demographic characteristics with regard to their years of experience as academics and postgraduate research supervisors.

It also emerged that the role of supervision was perceived as overpowering compared with other tasks of an academic. This further increased anxiety and being overwhelmed by research supervision, as well as a feeling of being blinded by the lack of knowledge on how to effectively fulfil this role:

Trustworthiness of the findings was achieved through: (i) credibility; (ii) depend­ ability; and (iii) triangulation. Credibility was achieved by member checking of the themes that emerged from the interviews. This allowed for congruency in the researcher’s meaning of the data to that of the intended meaning from the participants. Dependability of the data collected was ensured through an audit trail. Given that this study had two researchers, both served as peer reviewers of the individual in-depth interviews, the level of probing, and the sequence in terms of how the data were collected. Triangulation of data was achieved through the use of individual in-depth interviews, field notes during the interviews and a self-reported questionnaire. The use of multiple sources of data increased the certainness of the data gathered with regard to postgraduate research supervision.

Limitations of the study

While efforts to avoid researcher bias was controlled by reflection and bracketing, the researchers being academics involved in postgraduate research supervision was a limitation.

Sample description

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Research ‘ It is frustrating, research supervision takes most of my time … and I also teach clinical modules so need to do clinical rounds with the students as well … .’ ‘ … it becomes frustrating to manage all the roles and task of an academic … research supervision takes most of my time, especially if you are doing it for the first time … and at the same time we are expected to do research publications for ourselves … .’

Contributing to the feelings of being overwhelmed and frustrated, there were no guidelines or models of research supervision that they could use to assist them. Therefore, participants relied on their previous experience of being supervised in their own studies to guide them in research supervision. Furthermore, their own experiences left them feeling doubtful and frustrated with the supervision: ‘ … there are no information or courses I attended … I have mainly focused on how I was supervised when I was a student … .’

‘I supervise based on how I was supervised during my studies … you learn at the same pace as the student you are supervising, I feel uncertain if I’m doing the right thing … .’

‘I am always feeling unsure if I am doing the right thing … there is nothing to guide us. You become frustrated not knowing the right way to do things.’

Pressure to perform Participants felt that they experienced pressure to perform with the research students allocated to them. There was awareness of an expectation from the institution to accelerate postgraduate graduation rates. Furthermore, the participants who were new to research supervision noted the pressure they experienced with having to be skilled and providing quality supervision: ‘ … you always have a long list of postgrad students that need supervision … you have to finish them at a fast pace because next year your load just gets more … .’

‘We are told they [students] need to be completed in the minimum time … our performance as an academic is based on how many students you can graduate.’

‘Some of us have just completed our own qualifications and we are expected to supervise … it puts a lot of pressure because students are expecting quality supervision … .’

Some participants noted that the overwhelming pace of being expected to provide research supervision did not facilitate a learning pace where they could find their own niche area in the Department of Nursing and style of research supervision: ‘I try to read as much as I can on the student’s topic … but because I have so many students to supervise … it is difficult to get your own style to supervise.’

‘There are many students … they all come to see you at the same time … one cannot think about what is my way of supervising … or to even think about what area is my area of research.’

Getting the balance right Participants had many mechanisms of coping with supervision, despite the absence of a formal postgraduate research supervision programme to support the academics. Participants described strategies such as group or cohort supervision and using opportunities such as coffee mornings with

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postgraduate students to foster an equal relationship between student and supervisor. The participants felt that these efforts contributed towards a positive research supervision experience: ‘I find it easier to work on the same aspect with all my students … I get them all together and go over the theory of it … then we go back to individual contact supervision … it avoids repeating the same aspects to all the students … .’

‘I make it very social for the first meeting, I try to break the barriers as much as possible … it helps students … gives them a space where they can feel free … to talk about their fears of research.’

Participants also noted that postgraduate students’ expectations of what they wanted from their supervision experience added to the stress of supervising.

A lack of clear role definition and task allocation of a supervisor has sometimes resulted in hostility and conflict with students, who expected more from the supervision relationship: ‘It is frustrating when students expect you to do things like editing and formatting the document … some even expect you to help with literature reviewing … they don’t want to learn these skills on their own.’

‘I end up even doing grammar and editing and re-writing paragraphs … so I’m not sure if doing so much as part of supervision is also contributing to me feeling fatigued all the time with supervision … .’

Participants thought that creating peer support learning among the students helped supervisors achieve a balance. They felt that this helps in alleviating the unexpected expectations that students tend to have in terms of their own self-directed learning and independence: ‘I like to have at least one session each semester where I get all my students together just for a update … this helps students to stay on track because they see where their colleagues are so they don’t want to fall behind … .’

‘I encourage students to learn from one another … it becomes easier for them to network among each other … it helps me as well, because I’m not burdened with teaching each one the same thing.’

Self-reflection and experiential learning facilitated postgraduate research supervision. Participants used their own experience as a means of trying to improve their role as supervisor: ‘I try to improve how I supervise … I use previous supervision experiences with my current students … I try to do things differently to avoid the same mistakes … .’

Discussion

Modes of supervision

This study showed that a face-to-face supervision style was the predominant practice used. The literature supports this finding, arguing that more inexperienced academics use such traditional methods of supervision.[7] Overwhelmed and frustrated Inaccessibility of core information with regard to supervision models, styles and norms in effective supervision practices has been documented to contribute towards dissatisfaction among academics.[8,10] Moreover, ineffective supervision and poor graduation rates were predominately reported in environments with few supervision support documents or little training.[1,2,5] This study confirmed the importance of these documented research supervision support factors, as feelings of being overwhelmed

Research and frustrated were expressed in the context of not having supervision support. We also found that in the absence of supervision guidelines or models participants relied on their own experience to supervise, which often left participants feeling doubtful and frustrated. The literature reports that poor guidelines and support structures for academics, especially novice supervisors, contribute towards negative experiences with regard to the student supervisor relationship, especially as supervisors experience difficulty in balancing the time constraints of other academic roles with the demands of producing graduates at an accelerated rate and at the same time ensuring quality research graduates.[2,4,11] Pressure to perform The institutional expectation of accelerating postgraduate degree comple­ tion in the minimum time was a source of pressure for the supervision participants. Many authors have noted that higher education institutions are accelerating postgraduate research as a response to the global trend of research productivity being regarded as a commodity in the knowledge production economy.[2,4,10] Authors have supported our experiences that the drive for completion of postgraduate research supervision may contribute to frustration among academics, especially in terms of honing their own supervisory style.[2] Moreover, the literature indicates that while university systems have changed in terms of the political and economic environment and the research funding contestability, academics have not been supported to cope within this changing context.[1,2,4] Getting the balance right Establishing an interactive supervisory style allows supervisors to cope with the changing context and multifaced roles of being a clinician, academic, research mentor and supervisor.[1,10,11] The use of peer mentoring and cohort supervision, such as that expressed in this study as coping strategies towards research supervision, has been documented as having many beneficial effects.[12] The findings indicated that academics try to cope with and adjust to the demanding context of providing postgraduate research supervision coupled with other academic roles. The study also showed the use of peer learning and cohort supervision as methods that participants used to try to

establish a balance between their academic roles and research supervision.

Using forum sessions, cohort supervision and making the supervision interaction a social event is a method of allowing norms and expectations to be communicated early in the supervision relationship to avoid possible conflict and disharmony between student and supervisor.[10,11] It is also supported in the literature as a coping technique to assist supervisors in dealing with large supervision loads.[12]

Conclusion

This study explored the current burden of supervision experienced by nurse academics. Experiences of frustration, loss of control and difficulty in managing the multifaceted role of being an academic with a high number of postgraduate research students requiring supervision were expressed by the participants. Furthermore, the study reported on the coping strategies such as peer-supported learning sessions, cohort supervision and making supervision a social interaction between student and supervisor. We highlighted the importance of standardised training sessions and guidelines to support novice academics in supervision.

References 1. Bruce C, Stoodley I. Experiencing higher degree supervision as teaching. Stud High Educ 2013;38(2):226-241. [http://dx.doi.org/10.1080/03075079.2011.576338] 2. McCallin A, Nayar S. Postgraduate research supervision: A critical review of current practice. Teach High Educ 2012;17(1):63-74. [http://dx.doi.org/10.1080/13562517.2011.590979] 3. Council on Higher Education. Postgraduate Studies in South Africa: A Statistical Profile. A Report Commissioned by the Council on Higher Education. Pretoria: Council on Higher Education, 2009.

4. Chireshe R. Research supervision: Postgraduate students’ experiences in South Africa. J Soc Sci 2012;31(2):229234.

5. Kishun R. The internationalization of higher education in South Africa: Progress and challenges. J Stud Int Educ 2007;11(3):455.

6. Rowley J. Is higher education ready for knowledge management? Int J Educ Dev 2000;14(70):325-333.

7. Severinsson E. Research supervision: Supervisory style, research-related tasks, importance and quality – part 1.

J Nurs Manage 2012;20:215-223.

8. Halse C, Malfroy J. Retheorizing doctoral supervision as professional work. Stud High Educ 2010;35(1):9-92. [http://dx.doi.org/10.1080/03075070902906798] 9. Manathunga C. The development of research supervision: ‘Turning the light on a private space’. Int J Acad Dev 2005;10(1):17-30. [http://dx.doi.org/10.1080/13601440500099977] 10. Abiddon NZ, Ismail A, Ismail A. Effective supervisory approach in enhancing postgraduate research studies. Int J Human Soc Sci 2011;1(2):206-217.

11. Halse C. ‘Becoming a supervisor’: The impact of doctoral supervision on supervisors’ learning. Stud High Educ 2011;36(5):557-570. [http://dx.doi.org/10.1080/03075079.2011.594593] 12. Wisker G, Robinson G, Shacham M. Postgraduate research success: Communities of practice involving cohorts, guardian supervisors and online communities. Innov Educ Teach Int 2007;44(3):301-320. [http://dx.doi.org/ 1080/14703290701486720]

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Research Examining the effects of a mindfulness-based professional training module on mindfulness, perceived stress, self-compassion and self-determination S Whitesman,1 MB ChB; R Mash,2 MB ChB, DRCOG, DCH, MRCGP, FCFP, PhD 1

Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Institute for Mindfulness South Africa, Cape Town, South Africa

2

Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Corresponding author: S Whitesman (simonw@lantic.net)

Background. Mindfulness-based interventions (MBIs) have been shown to be effective in a wide range of health-related problems. Teaching and research with regard to MBIs have largely been conducted in the USA and Europe. The development of teachers of MBIs requires that they embody the practice of mindfulness and acquire pedagogical competencies. Stellenbosch University and the Institute for Mindfulness South Africa have launched a new and innovative training programme consisting of 4 modules, with a blend of residential retreats and e-learning. Internationally, this is the first study that specifically investigates the effects of mindfulness on the mental state of health professionals being trained to teach MBIs in their clinical practice.

Objectives. To evaluate the first 9-week module in terms of its effect on mindfulness practice, self-determination, self-compassion and perception of stress.

Methods. This is a before-and-after study of 23 participants, using 4 validated tools: Kentucky Inventory of Mindfulness Skills, Self-Determination Scale, Self-Compassion Scale, Perceived Stress Scale.

Results. There were significantly increased scores (p<0.05) for all 4 aspects of mindfulness practice (observing, describing, acting with awareness and accepting without judgement) and self-compassion. There was also a significant decrease in the perception of stress, but no effect on self-determination scores, which were already high at baseline.

Conclusion. Potential teachers of MBIs in South Africa demonstrated significant gains in their own mindfulness practice and self-compassion as well as decreased perception of stress during the first module of the training programme. Further research will follow as this group completes the entire programme.

Afr J Health Professions Educ 2015;7(2):220-223. DOI:10.7196/AJHPE.460

Mindfulness is moment-to-moment awareness and can be intentionally cultivated by paying attention in a specific way, i.e. in the present moment, non-judgementally, nonreactively and open-heartedly.[1] While mindfulness is a core element of Buddhist philosophy, early Western psychologists, such as William James, recognised the relevance of mindfulness, although it was not until the 1980s that the academic literature began to earnestly grapple with and fully understand its construct and application.[2] More generally, high mindfulness scores have been shown to predict selfregulated behaviour, positive emotional states and improved psychological wellbeing.[3] High levels of mindfulness have also been shown to correlate inversely with dissociation, alexithymia, and general psychological distress.[4] Mindfulness-based interventions (MBIs) have been developed to reduce symptoms across a wide range of populations and disorders, such as anxiety and depression, chronic pain, irritable bowel syndrome, HIV/AIDS and eating disorders.[5] Research shows that mindfulness-based approaches induce neuroplastic changes in the brain, especially the frontal-limbic axis,[6] enhance humoral immunity,[7] and may reduce relapse in patients who abuse substances.[8] MBIs therefore have a therapeutic place in healthcare services, and healthcare professionals such as psychologists or family physicians have shown interest in learning how to teach MBIs to their patients. To deliver MBIs to patients, healthcare professionals have to acquire knowledge of the approach and be able to practise mindfulness. The training of professionals to deliver MBIs rests on a set of core competencies that are introduced and

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assessed over the course of the programme. These competencies include guiding formal mindfulness practices, facilitating group processes and having good relational skills, linking oneâ&#x20AC;&#x2122;s direct experience of mindfulness with course themes and embodying the qualities of mindfulness through modelling a particular way of being.[9] The secularisation of mindfulness in the form of MBIs and its strong research foundation has led to its growing popularisation. There is a risk that the mainstreaming of mindfulness may lead to a slow dilution in the integrity of the approach. In this context, the effective and ethical training of teachers to deliver MBIs in diverse contexts is an important development in the pedagogy of mindfulness. In South Africa (SA) it is the motivating principle behind the training programme being offered by the Faculty of Medicine and Health Sciences at Stellenbosch University in collaboration with the Institute for Mindfulness SA, a nonprofit organisation committed to the training, research and application of MBIs. The Certification in Mindfulness-Based Interventions is a 60-credit training, which provides participants with experiential and theoretical exposure to mindfulness and mindfulness-based approaches in a supportive learning environment, with a view to professional application within existing spheres of expertise.

The training consists of 4 modules structured as a series of 8 - 10 week courses. Methods of learning combine residential training retreats and distance learning strategies, including online supervision and discussion, self-directed mindfulness practice with formal techniques and integration of mindfulness into daily life, practising and exploring teaching skills

Research (such as guiding practices and inquiry), self-reflective journaling, reading and critiquing peer-reviewed literature and writing essays for assessment purposes.

The 4 modular themes are as follows: Module 1. Mindfulness from the inside-out: An introduction to mindfulness and mindfulness-based approaches. The objective of this module is for participants to begin to explore the practice of mindfulness experientially and understand the theoretical basis and clinical context of its application.

Module 2. Blending form and essence: Exploring the key elements of a mindfulness-based intervention. The intent of this module is to understand the architecture, essential content and process of an MBI. Module 3. The ground beneath our feet: The foundations of mindfulness. The aim of module 3 is for participants to experience the depth of mindfulness practice and the ethos from which it arose, to encounter the framework for exploring suffering and its transformation, and to consider the relationship between the source of these teachings and their contemporary expression.

Module 4. Mindfulness at work: Refining the practice, refining the teaching, and the space between. The purpose behind the final module is to translate the theory into practice and to consider how to develop a personal intention and capacity for teaching through intensive exploration of guiding mindfulness practices in a variety of contexts under peer supervision.

Most of the formal training programmes in mindfulness-based approaches take place in the USA and Europe, up to and including Master’s level degrees. Our training programme is the first of its kind in SA and research into its uptake, effectiveness, applicability and impact on participants and the communities they serve is essential.

While MBIs are increasingly viewed as structured stepwise approaches to various health-related issues, the ethical debate among those offering university-based training programmes focuses on the centrality of the teachers’ embodiment of the qualities of mindfulness itself (such as presence, centredness, compassion) and the effect of the subjective state of the teacher on the communication and uptake of the curricular elements by the participants.[9] In this context, monitoring and evaluating the inner states of those undergoing teaching training development – and continuing this evaluation process after completion of the training – is potentially an important addition to the growing literature on the pedagogy of mindfulness.

The essential quality of mindfulness is a combination of heightened attentional capacity and compassion. The latter is the ability to be receptive to, understanding of and responsive to our suffering and to that of others. In this context, there can be no compassion separate from self-compassion. Furthermore, compassion encompasses a softening of the habitual tendency to judge the contents of the present moment in a manner that reduces engagement with the actuality of what is occurring.

This attitude of lessening the negating quality of mind is not a loss of discernment. Rather, the increase in mindfulness leads to a more refined and accurate perception of what is actually happening to and in an individual in successive moments of awareness, and the capacity to discern reality from reactivity. One of the consequences is to deal with stressful experiences on their own terms rather than from the reflexive overlay of conditioning. Such mindfulness becomes a valuable means to reduce the impact of psychological stress – much of which arises from a distorted perception of the present reality – at the same time embedding the capacity to respond rather than react to stressors within an individual’s

awareness. This capacity to choose a response to stressors, rather than simply reacting, is referred to as self-determination. Effective mindfulness practice, therefore, should lead to enhanced self-compassion and selfdetermination and a reduced perception of stress.

There are no studies in the literature that describe changes in levels of mindfulness and other mental capacities (e.g. compassion) as a result of such a professional training programme. The aim of this study was to evaluate the first module of the new short course on mindfulness practice at Stellenbosch University. The study evaluated changes in mindfulness practice, self-determination, self-compassion and perception of stress among participants.

Methods

Study design

We evaluated a short course on mindfulness, using before-and-after quantitative measures of mindfulness, self-determination, self-compassion and perceived stress.

Setting

Healthcare professionals participated in a 9-week short course on mindfulness practice at Stellenbosch University in collaboration with the Institute for Mindfulness SA. The short course was the first module in a larger programme on MBIs in healthcare that will follow. It consisted of an initial 1-week residential retreat, which intensively focused on the practice of mindfulness. The first day started at the Faculty of Medicine and Health Sciences, Stellenbosch University, with training in the computer laboratory and an overview of the course. The retreat was followed by 8 weeks of further theory, practice during normal daily living and reflection delivered by an internet-based program. The course was designed for healthcare practitioners, who were assessed on their contributions to online discussions and 2 final written assignments. One of the assignments was a personal narrative on their experience and exploration of mindfulness practice over the previous 8 weeks, and the second was a critique of the theory of mindfulness. The cohort consisted predominantly of medical practitioners and psychologists in clinical practice in private and state sectors. Participants enrolled in the training programme with the intention of learning how to teach mindfulness to patients in a secular context through deepening their personal practice while exploring the pedagogical aspects of its application.

Study population

The 23 students registered for the course were invited to participate in the study.

Data collection

Data were collected at the start of the course (at the introduction on day 1) and immediately after the end of the course as part of the feedback. The Kentucky Inventory of Mindfulness Skills is a validated 39-item self-report tool that was used to measure mindfulness on 4 scales: observing, describing, acting with awareness, and accepting without judgement.[10] The SelfDetermination Scale, a 10-item tool, assessed differences in people’s selfawareness and the extent to which they feel a sense of choice with regard to their behaviour.[11] The Self-Compassion Scale is a validated 26-item questionnaire that was used to rate how people responded to themselves in difficult times.[12] The Perceived Stress Scale is a validated 10-item questionnaire employed to measure perceived stress over the last month.[13]

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Research Data analysis

Quantitative data from the questionnaires were entered, checked and cleaned in a Microsoft Excel spreadsheet and analysed (in Statistica) with the assistance of the Centre for Statistical Consultation. Before-and-after numerical data from paired groups were compared with a nonparametric Wilcoxon-signed rank test.

Ethical considerations

The study was approved by the Health Research Ethics Committee, Stellenbosch University (N13/07/100).

Results

The study population comprised 18 women and 5 men with a mean age of 44.2 (range 32 76) years. The group included 5 psychologists, 5 medical practition­ers, 4 counsellors or coaches, 3 nurses, 3 professionals involved in leadership development, 1 social worker, 1 physiotherapist and 1 volunteer working with student groups.

Eighteen participants had some previous exposure to mindfulness practice, while 5 had no prior exposure. Eighteen were self-employed or working in the private sector, 4 worked in the public sector and 1 was doing voluntary work.

Table 1 presents the results of the questionnaires and shows a statistically significant improve­ ment in the practice of mindfulness. Participants showed a significant improvement in all 4 key dimensions of mindfulness: the ability to observe or direct one’s attention to internal and external phenomena; ability to non-judgementally describe thoughts and feelings; ability to act with full awareness of what one is doing in the present moment; and ability to accept or allow what is happening without judging the experience. Participants improved despite being a self-selected group, most of whom had some previous exposure to mindfulness practice.

Participants also improved significantly in all the dimensions of self-compassion, which measure how someone acts towards him/herself while experiencing difficult circumstances: selfkindness, avoiding self-judgement, identification with others, avoiding isolation, practice of mindfulness, and avoiding over-identification with difficulties.

Participants reported improved mindfulness and self-compassion and a significant decrease in their perception of stress during the previous month.

There was no change in the extent to which participants reported functioning in a self-

Table 1. Results of the questionnaires at baseline and follow-up (N=23) Baseline mean (95% CI)

Item

Follow-up mean (95% CI)

p-value

Kentucky Inventory of Mindfulness Skills (summative score) Observe (12 - 60)

40.9 (37.6 - 44.2)

47.1 (44.7 - 49.5)

<0.001

Describe (8 - 40)

28.4 (25.5 - 31.3)

30.3 (28.1 - 32.6)

0.018

Acting with awareness (10 - 50)

31.4 (28.5 - 34.3)

34.9 (32.2 - 37.5)

0.001

Accept without judgement (9 - 45)

32.7 (29.5 - 35.9)

35.5 (33.0 - 37.9)

0.016

16.5 (13.5 - 19.4)

12.8 (9.8 - 15.7)

0.012

Humanity (1 - 5)

3.3 (3.0 - 3.7)

3.8 (3.5 - 4.1)

0.005

Isolation (1 - 5)

3.4 (3.0 - 3.8)

3.8 (3.4 - 4.1)

0.032

Judgement (1 - 5)

3.2 (2.8 - 3.6)

3.6 (3.3 - 4.0)

0.012

Kindness (1 - 5)

3.3 (2.9 - 3.7)

3.8 (3.4 - 4.1)

0.002

Mindful (1 - 5)

3.4 (3.0 - 3.9)

3.8 (3.5 - 4.1)

0.051

Over-identified (1 - 5)

3.1 (2.8 - 3.5)

3.4 (3.1 - 3.8)

0.047

Total (1 - 5)

3.3 (3.0 - 3.6)

3.7 (3.4 - 3.9)

0.002

Aware (1 - 5)

4.0 (3.7 - 4.3)

4.0 (3.8 - 4.3)

0.681

Choice (1 - 5)

3.8 (3.5 - 4.2)

4.0 (3.8 - 4.3)

0.117

Total (1 - 5)

3.9 (3.7 - 4.2)

4.0 (3.8 - 4.2)

0.346

Perceived Stress Scale (summative score) Perceived Stress Scale (0 - 40) Self-Compassion Scale (mean score)

Self-Determination Scale (mean score)

CI = confidence interval.

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determined way. This especially relates to a sense of choice and control over one’s behaviour. The reported self-determination was relatively high at baseline and did not change significantly during the course.

Discussion

Internationally, this is the first study that specifically investigates the effects of mindfulness on the mental state of those being trained to become teachers of mindfulness-based approaches.

The results suggest that the initial stages of the abovementioned training at Stellenbosch University increased levels of self-compassion and mindful­ ness, which were accompanied by a decrease in the perception of stress.

There is an emerging literature on MBI teacher training that focuses on pedagogical elements. This literature speaks in depth to the core competencies required and offers a framework in which professionals training to teach MBIs are assessed.

Assessment focuses on skills development and capacity to communicate the key elements of a curriculum effectively, skillfully, compassionately and in an embodied way.[14] The initial data in this study suggest that compassion, one of the core elements of mindfulness, is enhanced with this training methodology and serves to support one of the key aspects required in teacher development.[14] The complex and multi-levelled challenges in our society demand innovative approaches to integrating mindfulness, without compromising the standards of training, leading to benefit in the therapeutic domain. The course offered at Stellenbosch University follows the international trend of combining residential and distance learning elements, although the curriculum structure is unique to this programme, considering cost, context and accessibility to make the training available to healthcare professionals in other African countries.

There are a number of potential benefits of training professionals in mindfulness-based approaches. Mindfulness and compassion are universal capacities and may potentially be used in diverse contexts. MBIs can be delivered in group format at primary care level and at relatively low cost (one only needs a room and teacher fees), is highly participatory and empowering for participants, and the skills acquired may subsequently be developed beyond the conclusion of a programme at no cost. Furthermore, MBIs are highly adaptable in terms of structure, duration and language without losing the essential elements or thread of the curriculum. Research

Research on the implementation of MBIs in the inner cities in the USA supports this adaptability.[15] However, similar contextual adaptations in Africa remain to be explored.

The lack of a control group, and participants in the training programme having been self-selected, limits the generalisability of these findings. It is possible that unmeasured confounding factors influenced the results, although none were identified. It is also possible that obsequiousness bias could have influenced the responses of the participants to the questionnaires, although the follow-up questionnaire was completed online and not in the presence of the tutor. Moreover, this is the first of 4 modules; at this stage conclusions cannot be drawn with regard to the effects on the overall training programme.

Ongoing research might consider whether the inner state of the teacher correlates with the therapeutic outcome in MBIs. There is evidence for this in other contexts, where increased levels of empathy among primary care physicians correlated with a reduction in diabetic complications.[16] High workload, low numbers of healthcare workers, poor infrastructure and an unsupportive organisational culture all contribute to high levels of stress, burnout and depression.[17] Quality of care and the ability to care for others diminish with burnout and lower levels of resilience among healthcare professionals. The changes seen in this study in levels of mindfulness, self-compassion and stress may not only help to better prepare healthcare professionals as teachers of MBI but also have a positive impact on their clinical engagement and quality of care due to enhanced wellbeing and resilience.[18] In the SA context, ongoing research into the impact of healthcare professional training programmes, based on the practice of mindfulness, should be explored in educational and clinical settings.

Conclusion

The first module of a training programme in MBIs led to significant improvements in mindfulness practice and levels of stress and self-

compassion among participating healthcare professionals. There was no change in the degree of self-determination. Such changes may assist healthcare professionals to become teachers of mindfulness practice and be more resilient in the clinical workplace. Further research is needed to evaluate the effect of all 4 modules of the training programme.

References 1. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.

15th ed. New York: Delta Trade Paperback/Bantam Dell, 2005.

2. Stanley S. Intimate distances: William Jamesâ&#x20AC;&#x2122; introspection, Buddhist mindfulness, and experiential inquiry. New Ideas in Psychology 2012;(2):201-211.

3. Baer RA, Smith GT, Lykins E, et al. Construct validity of the five facet mindfulness questionnaire in meditating and non-meditating samples. Assessment 2008;15(3):329-342.

4. Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice 2003;10(2):125-143.

5. Cullen M. Mindfulness-based interventions: An emerging phenomenon. Mindfulness 2011;2:186-193.

6. HĂślzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res 2011;191(1): 36-43. [http://dx.doi.org/10.1016/j.pscychresns.2010.08.006] 7. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med 2003;65(4):564-570.

8. Britton WB, Bootzin RR, Cousins JC, Hasler BP, Peck T, Shapiro SL. The contribution of mindfulness practice to a multicomponent behavioral sleep intervention following substance abuse treatment in adolescents: A treatmentdevelopment study. Substance Abuse 2010;31(2):86-97.

9. Crane RS, Kuyken W, Hastings RP, Rothwell N, Williams JMG. Training teachers to deliver mindfulness-based interventions: Learning from the UK experience. Mindfulness 2010;1:74-86.

10. Baum C, Kuyken W, Bohus M, Heidenreich T, Michalak J, Steil R. The psychometric properties of the Kentucky Inventory of Mindfulness Skills in clinical populations. Assessment 2010;17:220-229.

11. Sheldon KM, Ryan RM, Reis H. What makes for a good day? Competence and autonomy in the day and in the person. Personality and Social Psychology Bulletin 1996;22:1270-1279.

12. Neff KD. Development and validation of a scale to measure self-compassion. Self and Identity 2003;2:223250.

13. Cohen S, Kamarck T, Mermelstein RA. Global measure of perceived stress. J Health Soc Behav 1983;24:385-396.

14. Crane RS, Kuyken W, Williams JMG, Hastings RP, Cooper L, Fennel MJV. Competence in teaching mindfulnessbased courses: Concepts, development and assessment. Mindfulness 2012;3(1):76-84. [http://dx.doi.org/10.1007/ s12671-011-0073-2] 15. Roth B, Robbins D. Mindfuless-based stress reduction and health-related quality of life: Findings from a bilingual inner city patient population. Psychosom Med 2004;66(1):113-123.

16. Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 2012;87:12431249.

17. Rossouw L, Seedat S, Emsley RA, Suliman S, Hagemeister D. The prevalence of burnout and depression in medical doctors working in the Cape Town Metropolitan Municipality community healthcare clinics and district hospitals of the Provincial Government of the Western Cape: A cross-sectional study. S Afr Fam Pract 2013;55(6):567-573.

18. Goodman MJ, Schorling JB. A mindfulnes course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med 2012;43:119-128.

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Correspondence It is time to balance communitarianism and individualism in South African medical education To the Editor: Recent well-meaning global and South African (SA) reforms in medical education primarily consider an agenda of social accountability.[1,2] We are concerned that this approach may be the result of an excessive focus on the purpose of education to meet community needs (communitarianism) at the expense of the purpose of education to meet individual learner’s needs (individualism). If communitarianism and individualism are viewed as being at the opposite ends of a pendulum swing, we believe the pendulum is currently swinging too far away from individualism towards communitarianism, and that there should be a balance between these two.

A communitarian philosophy holds that any educational endeavour has wide social repercussions. If learners are not explicitly taught to act transformatively as ‘change agents’, education will only serve to further entrench inequality and injustice.[3] A deep consideration of the needs of the broader community in any educational effort is pertinent in post-apartheid SA to redress gross inequalities of the past.[4] Furthermore, it could be argued that community consideration is of particular importance in SA as the concept of Ubuntu may be an important part of societal norms: Ubuntu is described as a uniquely African philosophy that promotes the common good of society.[5] Compared with a communitarian philosophy, an individualistic philosophy at its core privileges human beings, while actions surrounding and beneficial to the wider society are considered secondary.[6] According to Hodges and Lingard,[7] the entire medical education enterprise is predicated on the individual. They assert that medical education discourses are underpinned by unexplored individualistic ideologies and quote examples of adult education theories and self-reflective practice as favouring individualistic thinking.[7] Generally, those who advocate a focus on community objectives in education do not criticise the idea of individual aims: excessive individualism, gained at a cost to certain community aims, is criticised.[8] Current medical education is criticised, as it places greater emphasis on the rights of the individual than on the individual’s response to society.

Accordingly, learners select careers based on their own ambition and not on society’s needs.[9] Traditionally, the two major positions of individualism and communi­ tarianism have been regarded as being mutually exclusive, as their basic assumptions and beliefs are deemed incompatible.[10] However, given the complexities of SA society and atrocities of the recent past, it would seem vital not to discriminate against either of these stances. Each philosophy can be seen as being more complex than simply all good or all bad. For example, there is a view that individualistic education can meaningfully contribute to a communitarian aim of social justice: if an individual works hard and succeeds, even if only in furthering his or her own goals, he or she will possibly contribute to a wider economy and society.[8] Concerns also arise around excessive communitarianism: should learners be used as a means to an end? A specific example of debate around treating learners and graduates as a means to an end can be found in discussions with regard to compulsory service programmes for recruiting healthcare workers in remote and rural areas: ‘Some commentators argue that it is contrary to the rights of the individual health worker.’[11]

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As a balance between these two divergent ways of thinking, Phenix[12] recommends that one should focus on the nature of the relationship between them: ‘The proper question is not whether we choose to be individual or social, but what shall be the quality of the individual-social complex.’ It seems apparent that current curricula and pedagogies in SA medical education generally do not take into account the relationship of the individual/social complex. As a specific example, pedagogies in SA medical schools are currently largely based on problem-based learning (PBL).[13] This is described as an instructional method where relevant problems are introduced at the beginning of the instruction cycle to provide the context and motivation for the learning that follows. PBL, despite intentions to foster collaboration and co-operation, has been described as fostering an individualistic philosophy.[14] To develop any relationship, there must be some type of dialogue; in medical education this could involve a tri-directional process of engagement between the learner, the university and the community it serves. Reports from SA universities are in favour of dialogue being enhanced, as educators actively encourage open and non-structured dialogue, e.g.: (i) by employing curricula that draw on learners’ lived experiences within their communities; and (ii) by promoting community-based participatory pedagogies.[15] In SA medical education, additional pedagogies to PBL may need to be considered, which foster learners in articulating and meeting their own challenges as individuals within the complexities of their society while simultaneously hearing and meeting the challenges of their broader community.

If an explicit aim of medical education in SA is to redress social injustice, then educators may need to take care that the pendulum does not swing so far from individualism that it negates the rights of learners as individual members of society. However, medical educators could review whether current curricula and pedagogies are excessively individualistic.

Considering pedagogies in addition to PBL, such as those that include learners’ experiences as community members and other community-based activities, may foster recognition of the essential need for both personal and communitarian aspects of medical education without advocating for the primacy of either.

L M Campbell Department of Family Medicine, College of Health Sciences, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa campbella@ukzn.ac.za

A J Ross Department of Family Medicine, College of Health Sciences, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa rossa@ukzn.ac.za

R G MacGregor Umthombo Youth Development Foundation, Hillcrest, South Africa gavin@umthomboyouth.org.za 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]

Correspondence 2. Van Heerden B. Effectively addressing the health needs of South Africaâ&#x20AC;&#x2122;s population: The role of health professions education in the 21st century. S Afr Med J 2013;103(1):21-22. [http://dx.doi.org/10.7196/samj.6463] 3. Watt J. Individualism and Educational Theory. Dordrecht: Kluwer Academic Publishers, 1971.

4. Dhunpath R, Vithal R. Alternative Access to Higher Education: Underprepared Learners or Underprepared Institutions? Cape Town: Pearson Education, 2012.

5. Gade C. What is Ubuntu? Different interpretations among South Africans of African descent. South African Journal of Philosophy 2012;31(3):484-503.

6. Ortelli J, Menashy F. Individual and community aims in education. In: Bailey R, Barrow R, Carr D, Mc Cathy C, eds. The Sage Handbook of Philosophy of Education. London: Sage Publications, 2010.

7. Hodges BD, Lingard L. The Question of Competence: Reconsidering Medical Education for the 21st Century.

New York: Cornell University Press, 2012.

8. Hargreaves DH. A sociological critique of individualism in education. British Journal of Educational Studies 1999;28(3):187-198.

9. Bleakley A, Bligh J, Browne J. Medical Education for the Future: Identity, Power and Location. New York: Apress Media LLC, 2011.

10. Griffin RS. Individualism, community, and education: An exchange of views. Educational Theory 1990;40(1):1-18.

11. Frehywot S, Mullan F, Payne P, Ross H. Compulsory service programmes for recruiting health workers in remote and rural areas: Do they work? Bull World Health Organ 2010;88:374-380. [http://dx.doi.org/10.2471/ BLT.09.071605] 12. Phenix P. Realms of Meaning a Philosophy for the Curriculum for General Education. New York: McGraw Hill, 1964.

13. Greysen SR. Medical education in sub-Saharan Africa: A literature review. Med Educ 2011;45:973-986.

14. Prince M. Does active learning work? A review of the research. Journal of Engineering Education 2004;93(3):223231.

15. Hartley A, Rule P. Exploring access as dialogue in an education and development certificate programme. In: Dhunpath R, Vithal R, eds. Alternative Access to Higher Education: Underprepared Learners or Underprepared Institutions? Cape Town: Pearson Education, 2012.

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CPD Questionnaire November 2015 True (A) or false (B): Optimising cognitive load and usability to improve the impact of e-learning in medical education 1.

Usability is a concept from the field of human-computer interaction, which describes how easy technology interfaces are to use, and is routinely evaluated and optimised in the software development industry.

Rising to the challenge: Training the next generation of clinician scientists for South Africa 2. Applicants to this Fellowship programme need only have a medical degree.

Effect of simulated emergency skills training and assessments on the competence and confidence of medical students 3. Clinical experience and the level of confidence have some predictive value in performance assessments when using standardised simulated scenarios.

Student compliance with indications for intravenous cannulation during clinical learning 4. One recommendation by the authors of this study is that medical educators should consider recent evidence and research in the area of simulation-based learning, as this appears to be an under-used didactic approach.

Implementing and managing community-based education and service learning in undergraduate health sciences programmes: Students’ perspectives 5. The authors propose 3 steps that can potentially enhance students’ communitybased education (CBE) and service learning (SL) experiences. Evaluating whether module outcomes have been met is part of the ‘Actions during CBE and SL’ step.

Preclinical medical students’ performance in and reflections on integrating procedural and communication skills in a simulated patient consultation 6. In this article, the authors refer to Neal et al., who demonstrated that trainees provided with a checklist beforehand performed just as well in their medical management and non-technical performance during a simulated episode.

A faculty-led solution to transport-related stress among SA medical students 7.

The Student Transport Project was found to alleviate financial but not emotional pressures for most students.

Nursing students’ perception of simulation as a clinical teaching method in the Cape Town Metropole, South Africa 8. Bloom’s Taxonomy has only recently been adopted as a popular framework for designing learning experiences, and to help educators to clarify their proposed objectives and to design suitable education and assessment methods.

Changing students’ moral reasoning ability – is it at all possible?

9. Research has supported a correlation between moral reasoning ability and good clinical performance.

Experiences of medical and pharmacy students’ learning in a shared environment: A qualitative study 10. Only the medical students of this study noted attitudes related to superiority and hierarchy.

Ethical dilemmas experienced by occupational therapy students – the reality 11.

The authors of this study identified inconsistencies in the students’ understanding of privacy and confidentiality. They clarified that ‘privacy’ refers to the notion of access to others, whereas ‘confidentiality' is restricted to information, how it relates to accessing such information and how it is applied.

Promotion of a primary healthcare philosophy in a community-based nursing education programme from the students’ perspective 12. The traditional teaching approach has been criticised for not equipping health professionals with the necessary knowledge and skills to work in rural, remote and under-resourced communities.

Dental students’ perceptions of practice management and their career aspirations 13. Similar to results from other studies on dental students, this study highlights that leadership and management were considered to be the most important skills to acquire other than clinical skills.

Second-year dental students’ perceptions about a joint basic science curriculum 14. The perception of dental students that the joint curriculum was too difficult and stressful was the most important finding of this study.

Self-regulation – the key to progress in clinical reasoning?

15. A model of self-regulated learning was described in this study as consisting of three phases, i.e. the planning phase, performance phase, self-reflection phase.

The meaning of being a pharmacist: Considering the professional identity development of first-year pharmacy students 16. The ‘development of a professional identity’ is primarily concerned with the process of integrating a new social identity into an individual’s self-identity.

Field trips as an intervention to enhance pharmacy students’ positive perception of a management module in their final year: A pilot study 17. The survey results showed that the field trips did not have a practically significant effect on students’ overall positive perception of the relevance of this module to practice.

An exploration of the experiences and practices of nurse academics regarding postgraduate research supervision at a South African university 18.

Email correspondence was found to be the most common mode of supervision in this study.

Examining the effects of a mindfulness-based professional training module on mindfulness, perceived stress, self-compassion and self-determination 19. This is the first study that specifically investigates the effects of mindfulness on the mental state of those being trained to become teachers of mindfulnessbased approaches, both locally and internationally.

20. This research showed that there were significant changes in the degree of self-determination.

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)

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