AJHPE Vol 9, No 1 (2017)

AJHPE

ISSN 2078-5127

African Journal of Health Professions Education

Sponsored by

March 2017, Vol. 9, No. 1

www.foundation.co.za

AJHPE

African Journal of Health Professions Education | March 2017, Vol. 9, No. 1 EDITORIAL 2

Fanning and refuelling the flickering flame of faculty development J van Wyk

REVIEW 3

South-South Cooperation in health professional education: A literature review L du Toit, I Couper, W Peersman, J De Maeseneer

RESEARCH 9

An integrated literature review of undergraduate peer teaching in allied health professions S van Vuuren

13 Developing a service-learning module for oral health: A needs assessment

R Ebrahim, H Julie 17 Barriers to continuous professional development participation for radiographers in Kenya

L G Kanamu, B van Dyk, L Chipeya, S N Kilaha 21 Specialty choice among dental students in Ibadan, Nigeria

K K Kanmodi, A I Badru, A G Akinloye, W A Wegscheider 24 Pioneering small-group learning in Tanzanian emergency medicine: Investigating acceptability for physician learners

A G Lim, H Geduld, K Checkett, H R Sawe, T A Reynolds 29 Self-directed learning: Status of final-year students and perceptions of selected faculty leadership in a Nigerian medical school – a mixed analysis study

T E Nottidge, A J N Louw 34 Self-regulated learning: A key learning effect of feedback in a problem-based learning context

A G Mubuuke, A J N Louw, S van Schalkwyk 39 Occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology

L Jacobs-Nzuzi Khuabi, J Bester, K Gatley-Dewing, S Holmes, C Jacobs, B Sadler, I van der Walt 44 Exploration of high-fidelity simulation: Nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting

T Munangatire, N Naidoo

EDITORIAL BOARD

EDITOR-IN-CHIEF Vanessa Burch University of Cape Town INTERNATIONAL ADVISORS Michelle McLean Bond University, QL, Australia Deborah Murdoch-Eaton Sheffield University, UK DEPUTY EDITORS Julia Blitz Stellenbosch University Jose Frantz University of the Western Cape Jacqueline van Wyk University of KwaZulu-Natal ASSOCIATE EDITORS Francois Cilliers University of Cape Town Rhena Delport University of Pretoria Lionel Green-Thompson University of the Witwatersrand Patricia McInerney University of the Witwatersrand Sindiswe Mthembu University of the Western Cape Ntombifikile Mtshali University of KwaZulu-Natal Anthea Rhoda University of the Western Cape Michael Rowe University of the Western Cape Marietjie van Rooyen University of Pretoria Susan van Schalkwyk Stellenbosch University Elizabeth Wasserman Stellenbosch University Elizabeth Wolvaardt University of Pretoria

HMPG

CEO and PUBLISHER Hannah Kikaya Email: hannahk@hmpg.co.za EXECUTIVE EDITOR Bridget Farham MANAGING EDITORS Claudia Naidu Ingrid Nye TECHNICAL EDITORS Emma Buchanan Paula van der Bijl PRODUCTION MANAGER Emma Jane Couzens

48 CPD questionnaire

DTP & DESIGN Clinton Griffin Travis Arendse CHIEF OPERATING OFFICER Diane Smith I Tel. 012 481 2069 Email: dianes@hmpg.co.za

AJHPE is published by the Health and Medical Publishing Group (Pty) Ltd, Co. registration 2004/0220 32/07, a subsidiary of SAMA HEAD OFFICE: Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext. 3, Pretoria, 0181 EDITORIAL OFFICE: Suite 11, Lonsdale Building, Lonsdale Way, Pinelands, 7405, Tel. 021 532 1281 | Cell 072 635 9825 Please submit letters and articles for publication online at www.ajhpe.org.za

ONLINE SUPPORT Gertrude Fani 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 2078-5127

Editorial

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Fanning and refuelling the flickering flame of faculty development The challenges of healthcare provision in South Africa have led to initiatives to strengthen the public sector,[1] increase the number of healthcare workers,[2] improve the relevance of training programmes,[3] and develop leadership capacity[4] to enable more positive health outcomes in communities. These initiatives in health have been implemented concurrently with developments in education with the hope to improve the quality of, and to transform, learning for the very diverse student population enrolled at institutions of higher learning. In this context, faculty development is offered to staff to stay abreast of pedagogical and disciplinary developments. Faculty development essentially includes efforts at individual, institutional or system level to capacitate staff with knowledge and skills in areas considered essential for their function as faculty members.

Healthcare educators generally become aware of the limitations in their educational understanding and practice when called on to teach students and junior members of staff. Although there is widespread agreement regarding the need to stay abreast with developments in one’s area of expertise, it is believed that additional reflective learning and educational skills are needed for optimal functioning across the sectors in which staff offer their clinical and educational services.

Facilitating learning for millennial students requires more active and interactive learning strategies; the appropriate use of technology to advance understanding; improved communication and learning support; and a greater willingness to engage with students and collaborators across space and time. Much has been written about professional learning and the conditions necessary for effective lifelong and reflective practice.[5] While methods to facilitate faculty development have changed with time, the reason for doing so has remained to improve the quality of the learning experience.

It is also widely known that a lifelong commitment to and investment in personal and professional development is needed. It is, however, possible that some members of staff and health professionals are not always able to identify their own learning needs[6] or prioritise time to engage in developmental activities.

In discipline-specific settings, provisions have been made for members to engage in continuous professional development, such as reported in this edition of AJHPE.[7] While efforts in low-income countries are severely hamstrung by the availability of training and resources,[8] it is believed that the lack of training in integrated teams continues to perpetuate the professional silos that are detrimental to the development of the competencies as needed for collective teamwork and effective leadership.[9] While some higher education institutions have implemented mandatory educational training modules for employees, the complexity of staffing of most health programmes results in only a fraction of teaching actually being done by trained educators. The absence of equal training demands for all who work in the sector thus simply increases the existing knowledge and training gap between university staff and their Department of Health counterparts, for whom compulsory training has not been mandated. The latter category of staff are, however, not exempted from teaching. In fact, the initiative to use a primary healthcare approach has seen more vociferous calls for education and training to be offered on distant and peripheral platforms. These discrepancies

2

March 2017, Vol. 9, No. 1 AJHPE

demand even greater collaboration among community-based practitioners and university stakeholders.

While faculty development initiatives have a better chance of success if implemented across longitudinal institutionalised frameworks,[10] providers are often met with resistance from those who seemingly ‘go through the motions’ to satisfy institutional regulations. These participants, while physically present, choose to engage only superficially with training, thus defeating its purpose.

It is therefore desirable that academics and clinical teachers alike become motivated to engage in ongoing training and educational debates, as they understand its inherent benefits for improved interactions with students and patients. Institutions should also recognise and value the impact of training in translating knowledge to practice and ultimately on improving health outcomes.[9] Despite technological developments in modes to deliver training, users in low- and middle-income countries are still affected by resource limitations and poor connectivity. Training will therefore need to be designed in consultation with stakeholders, with the methods of delivery being greatly dependent on the infrastructure and resource allocation of local settings.

While it is anticipated that the faculty development flame may initially be ignited through external drivers, such as legislative requirements, it is hoped that individual professional gains and an enhanced educational climate will fan the flame for sustained internal motivation to stay the course.

Jacqueline van Wyk Department of Clinical and Professional Practice, Nelson R Mandela School of Clinical Medicine, College of Health Sciences, University of KwaZuluNatal, Durban, South Africa vanwykj2@ukzn.ac.za 1. Matsoso MP, Fryatt R. National Health Insurance: The first 18 months. S Afr Med J 2013;103(3):154-155. http:// dx.doi.org/10.7196/samj.6601 2. Motala M, van Wyk J. Cuban medical collaborations: Contextual and clinical challenges. Afr J Health Professions Educ 2016;8(2):129. http://dx.doi.org/10.7196/ajhpe.2016.v8i2.641 3. Naidoo D, van Wyk J, Joubert RW. Exploring the occupational therapist’s role in primary health care: Listening to voices of stakeholders. Afr J Prim Health Care Fam Med 2016;8(1):1-9. http://dx.doi.org//10.4102/phcfm. v8i1.1139 4. Frantz JM, Bezuidenhout J, Burch VC, et al. The impact of an educational faculty development programme for health professionals in Sub-Saharan Africa: An archival study. BMC Med Educ 2015;15(28):3-9. http://dx.doi. org/10.1186/s12909-015-0320-7 5. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ 2009;14(4):595-621. http://dx.doi.org/10.1007/s10459-007-9090-2 6. Davids JM. Continuing professional development in nursing. MPhil thesis. Stellenbosch: Stellenbosch University, 2006. http://hdl.handle.net/10019.1/2816 (accessed 13 March 2017).

7. Kanamu LG, van Dyk B, Chipeya L, Kilaha SN. Barriers to continuous professional development participation for radiographers in Kenya. Afr J Health Professions Educ 2017;9(1):17-20. http://dx.doi.org/10.7196/AJHPE.2017. v9i1.605 8. Munangatire T, Naidoo N. Exploration of high-fidelity simulation: Nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting. Afr J Health Professions Educ 2017;9(1):44-47. http://dx.doi. org/10.7196/AJHPE.2017.v9i1.739 9. 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 10. McLean M, Cilliers F, van Wyk J. Faculty development: Yesterday, today and tomorrow. AMEE Guide No. 3. Med Teach 2008;30(6):555-584. http://dx.doi.org/10.1080/01421590802109834

Afr J Health Professions Educ 2017;9(1):2. DOI:10.7196/AJHPE.2017.v9i1.913

Review

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

South-South Cooperation in health professional education: A literature review L du Toit,1 BA Hons, MA (Development Studies); I Couper,2 BA, MB BCh, MFamMed, FCFP (SA); W Peersman,3 MA, PhD; J De Maeseneer,3 MD, PhD 1

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

2

Ukwanda Centre for Rural Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

3

Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Ghent University, Belgium

Corresponding author: I Couper (icouper@sun.ac.za)

In the literature on the evolution of funding approaches there is criticism of traditional funding strategies and the promotion of inclusive models, such as South-South Cooperation (SSC) and triangular models. The latter are felt to have a number of advantages. This article has four broad objectives: (i) to present a literature review on the evolution of Southern approaches to development co-operation; (ii) to indicate examples of current co-operative programmes in health and health professional education in Africa; (iii) to assess the advantages and disadvantages of these models; and (iv) to mention some emerging issues in monitoring and evaluation. The Boolean logic approach was used to search for applicable literature within three topic layers.

Searches were conducted using PubMed, PLoS and other accessible databases. An initial draft of the article was presented to a group of academics and researchers at the Flemish Inter-University Council (VLIR-UOS) Primafamed annual workshop held in August 2010 in Swaziland. Comments and suggestions from the group were included in later versions of the article. It is important to note that the existence of various funding models implemented by a variety of actors makes it difficult to measure their effects. In health and health professional education, however, SSC and triangular models of aid provide conditions for more effective programming through their focus on participation and long-term involvement. With an eye towards evaluating programmes, a number of salient issues are emerging. The importance of context is highlighted.

Afr J Health Professions Educ 2017;9(1):3-8. DOI:10.7196/AJHPE.2017.v9i1.541

International aid can take on a number of forms. Traditionally, official development aid via governments and global institutions is provided by members of the Development Assistance Committee (DAC) of the Organisation for Economic Cooperation and Development (OECD).

Funding through these channels is commonly referred to as DAC funding.

It is, however, important to note that various other players are also active in the global aid arena, such as international foundations, non-governmental organisations (NGOs), inter-governmental organisations (INGOs) and private funders.[1,2] There is a global debate on the effectiveness of different implementation models of aid and the eventual measurement of impacts and outcomes on recipient countries and populations. There is much theorising over the intended outcomes of development and, therefore, by implication, what aid aims to achieve. The current focus in discussions around development shows a relatively holistic conception of wellbeing and quality of life, rather than narrowly defined economic measures.[3] There is furthermore an expressed need to understand the desires and intentions of all the parties involved in the aid relationship, from the political/foreign policy intentions of donors to the goals of recipients, and how these intentions and the consequent relationships were formed historically.[4] In the literature on the evolution of approaches to funding there is a trend towards criticism of traditional funding modalities and the promotion rather of more inclusive models of aid, such as South-South Cooperation (SSC), comprising collaboration between partners in the global South, and triangular models, involving development partners supporting Southern collaborations.[1,5] The latter models are thought to have advantages,[6] notably a greater focus on partnerships and co-operation.

This article has four broad aims: firstly, to present the evolution of Southern approaches to development co-operation. SSC will be situated historically against the backdrop of aid generally in the post-World War II period.

There is a particular theoretical background to the concept of SSC, which is importantly derived from the post-colonial experience of Africa, Latin America and Asia, loosely referred to as the developing world in current discourse. This historical positioning gives rise to a number of criticisms of traditional aid models, from terminology to practice.

Secondly, it aims to indicate examples of current co-operative programmes in health and health science education in Africa, which are based on the principles of SSC and triangular aid. Some of these programmes (notably the United States President’s Emergency Plan for AIDS Relief (PEPFAR)) have evolved away from strategies based on vertical interventions, and at the time of writing were active in the brokering of co-operative partnerships and the facilitation of ‘twinning’ relationships.[7] The latter approach is in line with those typical of SSC and triangular models. In a policy document on approaches to collaborative projects, Rosseel et al.[8] mention a number of approaches combining Northern and Southern partners. The document makes specific reference to the social role of universities, and the role of higher education in human development, emphasising the role of institutions in promoting and supporting training that is beneficial to various communities, not only those communities in which they are based. Important to note is the key advantage of universities as co-creators of knowledge and facilitators of participation, producing types of science that are socially relevant to the needs of people. This is even more relevant in the area of health professions education.

March 2017, Vol. 9, No. 1 AJHPE

3

Review The third aim is to note the advantages of these funding models as policy responses to the criticisms levelled against traditional funding arrangements.

It is important to note that one cannot postulate a blanket assumption about the effectiveness of a funding model for all contexts. An understanding of the context where a programme is being implemented is of paramount importance in the decision on the funding model and definition of goals.

These Southern models have particular relevance in the field of health and health science education. Health and education have been identified as the main drivers of SSC; yet, they have been given little attention. There is a need, therefore, to focus on these because of the long-lasting benefits; health professional education has particularly long-term outcomes.

Finally, there is a discussion on some issues that are indicated as having particular relevance in the process of monitoring and evaluating these programmes. Some suggestions of future areas that may be important in research are made. It is felt that there is a strong need for monitoring and evaluating data that move beyond financial and logistical reporting.

Research that produces information on qualitative issues, such as buy-in and participation among partners, programme evolution over the long term, and contextual factors of programme design, is felt to be of importance when describing programme impacts and outcomes.

Methods

Literature searches for this article included those within three interlocking ‘layers’ of the topic, i.e.: • examples of and literature on SSC in the field of health science edu­ cation • examples of and literature on SSC in the field of health • examples of and literature on SSC in education.

Most information retrieval systems used on the web use Boolean logic when searching.[9] In this review, the Boolean logic approach was used to search for applicable literature within the three topic layers described above.

Databases searched included Pubmed, PLoS (Public Library of Science) and BMJ. Searches were also done using Google Scholar. Searches were conducted using different combinations of keywords, including: SouthSouth Cooperation, funding, health, education, health science, health science education, and Africa. Key literature sources were identified and their lists of references were reviewed to identify particular literature trails on the topic.

Criteria for the selection of literature included: (i) reference to international aid or co-operation in the field of education, and more specifically health science education; (ii) reference to aid and co-operation in the field of health; (iii) human resources for health; (iv) specific reference to SSC and/or triangular models of aid; and (v) focus on programmes in Africa.

Peer-reviewed books and journal articles were included, along with reports (not necessarily peer reviewed) from institutions and organisations.

Content was scanned using the criteria listed above. Those selected for analysis were then reviewed and their content tabulated, categorised in relation to the four aims.

It is noted that there is a dearth of literature on programmes that focus on health professional education specifically, which was the key area of interest in the current study. There was much to be found on SSC and triangular models in health on the African continent, and furthermore very broadly on programmes in education. The review strategy was therefore to start

4

March 2017, Vol. 9, No. 1 AJHPE

with the broader literature on SSC and triangular models in education, progressively narrowing down to literature on health, and then further narrowing down to health science education.

As a final stage in the process, an initial draft of the article was presented to a group of academics and researchers involved in health and health science education (from Europe and Africa) at the Flemish Inter-University Council (VLIR-UOS) Primafamed annual workshop held in August 2010 in Swaziland. Comments and suggestions from the group were included in later versions of the article.

Results

Historical positioning of aid and global presence of the South

Criticism of international development aid and different funding models begin by pointing out the conceptual problems with the terms associated with the field (such as global South), and the very idea of development itself.[10] Reference is made to the roots of the idea of development in Western, positivist ways of thought. It is posited that use of the concept and term has essentially disguised a close relationship between funding/aid, colonialism and the workings of global capitalism.[10] Critics of the concepts encapsulated in the traditional aid paradigm point out that the use of these discursive constructs in essence describes a relationship of inequality between the global North and South, between the First World and the Third World.[11] The term Third World as a concept emerged in 1952 in an article entitled Trois mondes, une planète by French demographer, historian and anthropologist, Alfred Sauvy. This article described the ideological division of the world during the Cold War, the term itself referring to countries, particularly those in the Middle East, South Asia, Latin America, Africa, and Oceania, that were not aligned with either the communist Soviet bloc or the capitalist North Atlantic Treaty Organization (NATO) bloc.[10] The original meaning of the concept therefore refers more pertinently to political alignment rather than to economic and social realities in these countries.

The Cold War had a particular impact on the implementation of aid for large parts of the 20th century. This conflict dominated the international policy stances of the then hegemonic states, i.e. the USA and what was then the Union of Soviet Socialist Republics (USSR), during the 1950s, with the two superpowers vying for ideological control over newly decolonised states in Africa, Asia and Latin America.

Partly in reaction to the experience of the Cold War in developing countries, and the perceived neocolonialist movement of international aid, SSC became prominent in development circles when Asian-African leaders met at the Bandung Conference, Indonesia, in 1955. The purpose of this meeting was to forge links in cultural and economic areas by and for the global South.

The Bandung Conference paved the way for the eventual establishment of the Non-Aligned Movement (NAM) in 1962, and finally the Group of 77 (G77) in 1964. The G77 issued a joint declaration at the conclusion to the United Nations (UN) Conference on Trade and Development in 1964. This declaration was based on the realisation that newly decolonised countries were at a disadvantage when it came to global trade and development, and that this disadvantage was endemic to the process of decolonisation. The vulnerabilities of the developing world in terms of international trade and labour division indicated the need to co-operate in leveraging international influence. Key in this era is the perception among countries of the global South that the funding flows of international aid were determining the

Review development agendas of recipient countries, more in line with the interests of donor countries than those of developing countries.[12] The collaboration of NAM therefore strongly reflected a desire among newly decolonised countries to participate in global trade and investment on equal terms. There is furthermore strong reference in the joint declaration of this conference to the need to address issues around development and living standards of developing world populations.[12]

SSC as distinct funding model

It is important to point out that the SSC and triangular models of aid form a specific type of funding model among various different types. Some authors[2,13] identify the funding community as comprising donors that do not form part of DAC, OECD and the Organization of the Petroleum Exporting Countries (OPEC). There is further grouping of these ‘others’ into the categories: emerging donors, SSC and Arab donors.[2] Three distinct funding models become apparent: the DAC model, the Arab model and the Southern model. SSC and triangular models therefore fall under the Southern group of funding modalities.[1] In terms of defining SSC, Sa e Silva[5] notes that SSC has probably existed since the very first independence movements in colonised nations. However, only in the 1940s did it acquire an institutionalised character. For the purposes of this article, and in line with the reference to the Bandung Conference, SSC is defined similarly to the view espoused by Sa e Silva. We will therefore demarcate our discussion to those initiatives displaying an institutionalised character, which fall under the banner of SSC.

Evolution of SSC

Sa e Silva[5] describes a very useful division of the three eras of SSC in the 20th century. It is interesting that this three-phase process mirrors the evolution of the development paradigm through its modernist, Marxist and postmodernist phases.

Phase 1. Self-reliance and political strengthening (1949 - 1979) The colonial period in many ways represents the modernist era of development, with its hallmarks of positivist thinking, and the belief in a linear, almost natural developmental process. This way of thinking implies that all countries are at a certain stage on one, single development continuum, and that underdeveloped countries therefore need to follow the path that has been followed by the ex-colonial powers. The modernist era of development, which characterises the period immediately after World War II, was facilitated by technical consultants and multilateral agencies, with the rise of the influence of multinational corporations furthermore being an identifying characteristic of this phase.[14] This history of colonialism and neocolonialism provides the backdrop to the start of various independence movements, and ideas around self-reliance (often referred to as de-linking from the world system), with widespread acknowledgement among newly decolonised states that the world economic system is exploitative of the global South. The idea of SSC in this context arose out of calls for collective action, presented as an ‘alternative to the traditional path of development’.[5] The G77 was interestingly referred to

by Tanzanian president, Julius Nyerere, as ‘the trade union of the poor’.[15] The Cold War backdrop to this phase provides a certain ‘flavour’ to the development discourse at the time: dependency theory and world systems theory emphasise the vagaries of capitalism and espouse values of socialism,

communalism and human need over market processes. This background therefore lent itself to the structuring of exchanges and co-operative agreements, especially between countries that promoted socialist ideals.[14] Phase 2. Demobilisation (1980 - 1998) The second definable phase of SSC was characterised by a certain sense of disillusionment, with the promises of socialist economics, self-reliance and the new international economic order. During these two decades, a number of countries in the global South faced similar domestic difficulties, i.e. high levels of foreign debt, high levels of domestic inflation, and economic recession. A decision by the USA in 1980 to increase interest rates by ~20% resulted in what is commonly referred to as the debt crisis for developing countries.[5] The demise of the Soviet block and the end of the Cold War during this period furthermore appeared to confirm the superiority of market-based economies over what seemed like the obvious failure of socialist systems.

This circumstantial evidence of the need to follow neoliberal economic policies can be seen at work in the implementation of structural adjustment programmes of the International Monetary Fund (IMF) and the World Bank; the programmes involved austere economic policy measures that were required to be implemented by a country seeking financial assistance from these bodies. During the 1990s, the net result of these structural adjustment programmes was to drastically cut government spending on social services, notably health, education and social assistance, in both the North and the South, but with particularly negative consequences in the global South, especially in Africa.[10] During this phase of development aid, there emerged a realisation among those in the global South (but certainly also visible in the aftermath of various movements around human and civil rights in the global North) that the goals of development have systematically been shown to be more about economics than social change.[16] Phase 3. Best practice transfer (1999 - present) As the developing world went through a phase of disillusionment with socialism, so there was also a stage of disillusionment with the ‘gospel’ of free market economics. The results of attempts by Southern countries to adopt the doctrines of the Washington Consensus (i.e. structural adjustment programmes) were far removed from the prosperity promised by neoliberal ideology. High levels of unemployment and poverty, coupled with less access to education and healthcare, saw the re-emergence of the situation that originally inspired SSC.[5] SSC increasingly became an official part of the foreign policies of various developing nations, with a number of trade agreements emerging between 2003 and 2004. Examples are the India-Brazil-South Africa (IBSA) trilateral forum and the Brazil-Russia-India-China-South Africa (BRICS) forum.[5,17,18] In this current era of SSC, there is an emphasis on the transfer of best practice policies and programmes. Therefore, the experiences of the developing world in terms of policy and programming are useful for discussion among other developing nations, as there is a sharing of similar domestic situations, problems and possible advantages. The approach of a linear development path so characteristic of modernist views earlier in the 20th century is replaced with a sense of exchange and co-operation around multiple experiences of development and social change. The current era furthermore expresses dissatisfaction among developing countries of the traditional development aid paradigm: strong criticisms emerged of the work

March 2017, Vol. 9, No. 1 AJHPE

5

Review developed by international agencies, highlighting their ineffectiveness in producing positive change in the South by means of development projects.[5] In the current phase of SSC the concept has increasingly been adopted as a co-operation tool rather than a political movement. Its politically correct character makes it an appealing tool for international agencies, which have increasingly changed their involvement in aid to the facilitation of South-South agreements and co-operative arrangements (as opposed to the sponsoring of projects).[5]

Health and health science education in Africa

In an era where Southern governments were dealing with the fall-out of structural adjustment programmes of the early 1990s, the Cuban healthcare model, focused on primary, community-based care, promised to be a particularly relevant approach in the developing world. The principles of community-orientated primary care emphasise the role of the social determinants of health (e.g. sanitation, education, housing, nutrition).[19] This model is different to the curative model that is largely associated with the colonial system in Africa, being more focused on preventive strategies. The primary care model furthermore has a particular focus on equity in access to care.[20] The understanding of the interaction between social realities and the health and wellbeing of people and communities, provides a unique vantage point from which to do research, to advocate and to design programming.[21] The impact of attention to the primary healthcare needs of populations in developing countries provides a unique lens through which to view larger processes aimed at human development.

There are therefore a number of good reasons for promoting the primary care approach in healthcare and health science education for developing countries. A health system based on the primary care approach has been shown in a number of studies (in the developed and developing world) to have the greatest impact on public health as measured, for example, by maternal and infant mortality rates.[22-24] In relation to the primary healthcare focus and SSC associated with healthcare and the training of health professionals, one cannot fail to mention the example of Cuban medical professionals in other parts of the developing world. Cuban involvement in co-operation around healthcare, specifically in Africa, can be traced back to the 1960s and the first era of Southern mobilisation focused on self-reliance.[20] An article in The Economist[25] noted that one in three Cuban doctors work abroad (mainly in other developing countries) at any given time. The Cuban model of co-operation in Africa has focused more on the building of capacity than on the provision of infrastructure, which is an approach characteristic of SSC programmes.

The co-operative initiatives around health and health science education mentioned in this article have very real intentions around the promotion of primary healthcare in developing countries in Africa. This is done mainly through the support of training, which promotes the recruitment and retention of relevant, effective medical professionals for the diverse settings in Africa. A number of current examples of SSC and triangular programmes in health science education in Africa are described.

CHESTRAD: Southern civil society dialogue on health and accountability The Centre for Health Sciences Training, Research and Development (CHESTRAD) international is an African-based non-profit organisation with support from donors in the UK and USA. The organisation’s main

6

March 2017, Vol. 9, No. 1 AJHPE

aim is to support dialogue and co-operation among various actors involved in health and health systems in Africa (and beyond) through advocacy activities based on reliable research.

CHESTRAD is active in a number of initiatives on the African continent aimed at health system strengthening and human resources for health. A number of initiatives, declarations and documents actively refer to the need to address human resource shortages in healthcare in Africa, including the Global Health Workforce Alliance, International Health Partnership, the United Nations Action Plan on Maternal and Child Health, the Millennium Development Goals and the African Health Workforce and Systems Strengthening Solidarity Programme.[26] PEPFAR initiatives in Africa PEPFAR is a broad programme aimed at addressing some of the health system problems on the African continent by supporting (through funding and technical assistance) programmes that are related to health and healthcare delivery, health systems and human resources for health.

Important to this initiative are the brokering of partnerships and ‘twinning’ agreements between health science education institutions in the global North and South. The twinning programmes are based more on the best practice model of co-operation, illustrating a general shift in approach between the initial PEPFAR programme (characterised by vertical programme delivery) and the second phase (focus on system strengthening and support).

MEPI and NEPI: medical and nursing education partnership initiatives The Medical Education Partnership Initiative (MEPI) and Nursing Edu­ cation Partnership Initiative (NEPI) programmes represent major collaboration between PEPFAR and its partner agencies, i.e. Health Resources and Services Administration (HRSA), the US Agency for International Development (USAID), and the PEPFAR country teams with a number of partner organisations. External partners included the World Health Organization (WHO) and a number of US- and Africa-based funding, teaching and research organisations.

The programme aimed at encouraging partnerships in Africa, supporting the development of skills and research capacity. There was a focus on collecting quality information on the health needs of countries on the African continent, system challenges and opportunities, as well as the production of health professionals in Africa. A further aim was to support the development of health education programmes in institutions in Africa, with the ultimate objective of increasing the production and retention of health professionals in Africa.

SAMSS: Sub-Saharan Medical Schools Study and African Medical Education Symposium The objective of the Sub-Saharan African Medical Schools Study (SAMSS) was to promote knowledge and dialogue among key stakeholders in Africa by sourcing and collating quality research and information on health and health systems. The study furthermore collected information on medical education programmes in Africa and co-operative arrangements (often called twinning agreements) among health science education institutions in Africa.[27] The promotion and development of national and global policies around human resources for health is increasingly being debated and discussed

Review in international forums, an example being the African Medical Education Symposium (AMES) held in Dar es Salaam, Tanzania.[28] Family Medicine Educational Consortium The Family Medicine Educational Consortium (FaMEC) worked in supporting the development of family medicine training, focusing on primary healthcare in southern Africa since 2003.

This co-operative model had as its later focus the building of partnerships between African countries in the development and establishment of training for family medicine in the framework of the Primafamed-network (www. primafamed.ugent.be). This phase supported the twinning of established family medicine programmes in South Africa (SA) with other countries in southern Africa, with the purpose of developing training and assessment methods.

This programme had at its core a belief that the experiences of Southern partners are sufficiently different from the experiences of the global North to create the understanding that ‘all the expertise was in the South’.[29]

Discussion

The literature describes the primary advantage of SSC and triangular approaches as being the increase in a sense of ownership among beneficiaries of aid. The major criticism against traditional funding relationships between North and South was that the lack of ownership and input in the process among the beneficiaries seriously affected the sustainability and costeffective­ness of programmes.[6] It is also felt that the South shares many common problems and issues, and can therefore provide more contextually appropriate experience and assistance.[6,11,12] The major criticism against traditional aid relationships was that it often introduced inappropriate technology and technical skills that did not match the environment in which these were supposed to work.

This led to higher costs and serious concerns around sustainability, as the recipients of the assistance could often not maintain the technology.[6,10,30] A number of salient issues are emerging in health and health science education. These issues are often, but not always, quite distinctive of the African context.

Variability of socioeconomic and sociocultural life worlds

Cultural understandings of health and medicine can be highly variable.

Primary care that focuses on the individual rather than the illness, can garner great synergy and impact when it is cognisant of traditional indige­ nous knowledge systems.[31] There is much opportunity to combine social teaching and research in health science education to make professionals more responsive to the needs of communities, and to promote and facilitate participation in the definition of health needs.

Cultural competence of learners and teachers

Related to the above, healthcare that is orientated around communities and sensitive to the contextual realities of people’s lives needs to take cognisance of socially and culturally defined ways of thinking about health, illness and healing.

Such a cultural competence is more representative of a set of intellectual skills (such as the ability to conduct a community assessment by using different data collection methods) than a particular type of course content.

Related to this issue is the need to produce skilled professionals who are well suited to the social and economic context of the many different settings in the developing world, and furthermore to define clearly what those skills and professional attributes are.[32]

The use of information and communication teaching techno­ logy across vast distances and in resource-poor settings A practical issue in teaching and skills development in southern Africa (and of course, further afield) relates to the use of technology that can bridge the vast distances between community-based health services and often urbanbased centres of teaching and research.[33]

Thinking about the development path

With reference to the discussion above on the evolution of development aid away from linear conceptions of development and growth, it is important to mention that the current paradigm of SSC and triangular aid does not easily escape these tensions. When it comes to training, research and engagement at a community level, there is often conflict between the ‘modern’ and the ‘traditional’, and the power relations associated with each.

It is important to consider the ability of teaching and training institutions to transcend these tensions, and a tendency among populations to classify the ‘modern’ with ‘imperialist’. Critical in this discussion is the use of language (as a medium of instruction, or to communicate with patients), how it relates to tensions and power struggles, and how it enables or disables the health professional and the patient.

Hountondji[34] refers to the process of grappling with the ‘colonial roots of science’ and the status of African countries on the ‘scientific periphery’.

He advocates the need for African institutions to own their own scientific traditions; this can only be achieved by the development of high-quality research and teaching on the continent, which forms the basis of a socially relevant tradition of research, teaching and practice.

Forces influencing the migration of medical professionals

A major field of research relates to the forces impacting on the supply of suitably qualified medical practitioners, especially for rural Africa.

The well-known process whereby medical professionals are trained in the developing world, only to then leave their countries of origin for better working and living conditions in the developed world, is described in the literature.[35] An increasing trend worth noting in this regard is the migration of professionals between different African countries, also with the idea of better living and working conditions in certain places, notably SA. This process results in acute losses in the developing world: not only does the provision of health services in the developing world suffer, the migration of a trained professional represents a significant loss in terms of training investment.

Describing and evaluating innovative programmes

There are a number of existing health science training programmes in the South that are truly innovative in terms of supporting students’ knowledge of social realities, community-based teaching, and community-based care.

Many Southern countries boast a long history of grappling with the social determinants of health, multiple policy reforms and varying success in either creating new approaches, or adapting old approaches to teaching for their contexts.[36] A large gap in knowledge currently refers to the lack of studies that evaluate the impact of existing programmes under current SSC and triangular co-operation models, especially over a significant period of time, producing longitudinal data. Here it is important to provide information on the quality of curricula, training methods, and the co-operative agreements themselves.

Beyond these issues, however, is a much larger question on the human impact of such initiatives, and how a programme affects the provision of services over

March 2017, Vol. 9, No. 1 AJHPE

7

Review a particular period of time. This broader impact needs to be described more effectively for the initiatives that are already in existence.

Harris and Tanner[30] highlight the need in this regard to strengthen structures in the global South that can produce quality ‘Southern knowledge’.

Betancourt and Schulz[37] point out the need for such evaluation work to help define what should be regarded as good practice or best practice, and what such initiatives should deliver.

Conclusion

SSC and triangular models reflect the historical situation of funding from the colonial era to the current era of co-operation. A number of current co-operative agreements in health and health professional education in Africa follow the SSC and/or triangular models of aid, which are thought to be advantageous in the field of health and health professional education.

With regard to these two aspects, SSC and triangular models of aid provide conditions for more effective programming through their focus on participation and long-term involvement. The need for ongoing funding for these kinds of initiatives remains, and they appear to provide the greatest opportunity for long-term developmental impact.

The existence of various funding models implemented by a variety of actors makes it difficult to measure their impact, but it is important to do so, with a broad development perspective. While context is important in evaluating programmes, common tools that monitor both outcomes and the extent of South-South collaboration, with the long-term benefits that accrue for all partners, are needed.

Acknowledgements. This work was supported by the Flemish Inter-University Council (VLIR-UOS) Primafamed project through direct funding of the Centre for Rural Health, University of the Witwatersrand, Johannesburg, where the research was based. A scholarship of short duration for the first author (LdT) was also provided for travel and accommodation in Ghent, Belgium, during the drafting of the article.

1. Walz J, Ramachandran V. Brave new world: A literature review of emerging donors and the changing nature of foreing assistance. Centre for Global Development. 2010. http://cgdev.org (accessed 16 January 2017).

2. Zimmerman F, Smith K. More actors, more money, more ideas for international development co-operation. J Int Dev 2011;23(5):722-738. http://dx.doi.org/10.1002/jid.1796 3. United Nations Development Programme. Human Development Report 2010. The Real Wealth of Nations: Pathways to Human Development. Geneva: UNDP, 2010. http://hdr.undp.org/en/content/human-developmentreport-2010 (accessed 16 January 2017).

4. Schraeder PJ, Hook SW, Taylor B. Clarifying the foreign aid puzzle: A comparison of American, Japanese, French and Swedish aid flows. World Politics 1998;50(2):294-323.

5. Sa e Silva MM. South-South Cooperation: Past and present conceptualisation and practice. In: Chisholm L, Steiner-Khamsi G, eds. South-South Cooperation in Education and Development. New York: Teachers’ College Press and HSRC, 2009.

8

March 2017, Vol. 9, No. 1 AJHPE

6. United Nations Development Programme. Online Handbook on South-South Cooperation: United Nations Development Programme Special Unit for South South Cooperation. 2006. http://handbook.southsouthconference. org (accessed 16 January 2017).

7. Walensky RP, Kuritzkes DR. The Impact of the President’s Emergency Plan for AIDS Relief (PEPFAR) beyond HIV and why it remains essential. Clin Infect Dis 2010;50(2):272-275. http://dx.doi.org/10.1086/649214 8. Rosseel P, de Corte E, Blommaert J, Verniers E. Approaches to North-South, South-South and North-SouthSouth Collaboration. A Policy Document. 2009. https://lirias.kuleuven.be/bitstream/123456789/229636/1/ POLICY_PAPER_VLIR_UWC__NSS.pdf (accessed 16 January 2017).

9. Frants VI, Shapiro J, Taksa I, Voiskunskii VG. Boolean search: Current state and perspectives. J Am Soc Inform Sci 1999;50(1):86-95. http://dx.doi.org/10.1002/(SICI)1097-4571(1999)50:1<86::AID-ASI10>3.0.CO;2-7 10. Rist G. The History of Development from Western Origin to Global Faith. London: Zed Books, 2001.

11. Chisholm L. Rhetoric, realities and reasons. In: Chisholm L, Steiner-Khamsi G, eds. South-South Cooperation in Education and Development. New York: Teachers’ College Press and HSRC, 2009.

12. G77. Joint declaration of the seventy-seven developing countries made at the conclusion of the United Nations Conference on Trade and Development. 1964. http://g77.org/doc/Joint%20Declaration.html (accessed 16 Jan­uary 2017).

13. Manning R. Will ‘emerging donors’ change the face of international co-operation? Dev Policy Rev 2006;24(4):371-385. http://dx.doi.org/10.1111/j.1467-7679.2006.00330.x 14. Nederveen Pieterse J. Development Theory: Deconstructions/Reconstructions. London: SAGE, 2001.

15. Nyerere JK. Ujamaa. The basis of African socialism. http://infed.org/mobi/julius-nyerere-lifelong-learning-andeducation/ (accessed 16 January 2017).

16. Tikly L, Dachi H. The new regionalism of African education: Limits and possibilities. In: Chisholm L, SteinerKhamsi G, eds. South-South Cooperation in Education and Development. New York: Teachers’ College Press and HSRC, 2009.

17. Abdenur A. The strategic triad: Form and content in Brazil’s triangular cooperation practices. In: Chisholm L, Steiner-Khamsi G, eds. South-South Cooperation in Education and Development. New York: Teachers’ College Press and HSRC, 2009.

18. Samoff J. Foreign aid to education: Managing global transfers and exchanges. In: Chisholm L, Steiner-Khamsi G, eds. South-South Cooperation in Education and Development. New York: Teachers’ College Press and HSRC, 2009.

19. Declaration of Alma-Ata. Declaration of International Conference on Primary Health Care, 6 - 12 September 1978, Alma-Ata, USSR. http://apps.who.int/medicinedocs/documents/s21369en/s21369en.pdf (accessed 16 January 2017).

20. Blunden M. South-south development cooperation: Cuba’s health programmes in Africa. Int J Cuban Studies 2008;1(1):1-11.

21. Gwatkin DR. The need for equity-orientated health sector reforms. Int J Epidemiol 2001;30(4):720-723. http:// dx.doi.org/10.1093/ije/30.4.720 22. Shi L, Starfield B, Kawachi I. Income inequality, primary care and health indicators. J Fam Pract 1999;48(4):275-284.

23. Shi L, Starfield B, Politzer R, Regan J. Primary care, self-rated health, and reductions in social disparities in health.

Health Serv Res 2002;37(3):529-550. http://dx.doi.org/10.1111/1475-6773.t01-1-00036 24. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970 - 1998. Health Serv Res 2003;38(3):831- 865. http://dx.doi.org/10.1111/1475-6773.00149 25. Dr Diplomat. Exporting medicine and influence. The Economist 2007;382(8513):35-36. http://economist.com/ node/8597159 (accessed 15 February 2017).

26. Dare O, Kunonga E, Sangowana O. Human Resources as the Driver of Health Systems Strengthening: Ondo State Nigeria. A Demonstration Site for the African Learning Sites Programme. Harare: CHESTRAD, 2010.

27. Mullan F, Frehywot S. The Sub-Saharan African Medical Schools Study: Data, Observation and Opportunity.

Washington: SAMSS, 2010. https://smhs.gwu.edu/medicine/sites/medicine/files/125.pdf (accessed 16 January 2017).

28. Sub-Saharan African Medical Schools Study. African Medical Education Symposium (AMES), 17 - 19 April 2010, Dar Es Salaam, Tanzania. http://samss.org/default.aspx (accessed 16 January 2017).

29. Flinkenflӧgel M, Essuman A, Chege P, Ayankogbe O, De Maeseneer J. Family medicine training in Sub-Saharan Africa: South-South Cooperation in the Primafamed project as a strategy for development. Fam Pract 2014;31(4):427-436. http://dx.doi.org/10.1093/fampra/cmu014 30. Harris E, Tanner M. Health technology transfer. BMJ 2000;321(7264):817-820. http://dx.doi.org/10.1136/ bmj.321.7264.817 31. Germond P, Cochrane JR. Healthworlds: Conceptualising landscapes of health and healing. Sociology 2010;44:307-324. http://dx.doi.org/10.1177/0038038509357202 32. Mash R, Downing R, Moosa S, de Maeseneer J. Exploring the key principles of family medicine in sub-Saharan Africa: International Delphi consensus process. S Afr Fam Pract 2008;50(3):60-65.

33. Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: Five years of distance continuing medical education and tele-consultations over the internet in French-speaking Africa. Int J Med Inform 2007;76(5-6):351-356. http:// dx.doi.org/10.1016/j.ijmedinf.2007.01.012 34. Hountondji P. Scientific dependence in Africa today. Res Afr Lit 1990;21(3):5-15.

35. Bundred PE, Levitt C. Medical migration: Who are the real losers? Lancet 2000;356(9225):234-236. http://dx.doi. org/10.1016/S0140-6736(00)02492-2 36. Lehmann U, Andrews G, Sanders D. Change and Innovation at South African Medical Schools: An investigation of Student Demographics, Student Support and Curriculum Innovation. Pretoria: Health Systems Trust, 2000.

37. Betancourt MC, Schulz NS. South-South Cooperation in Latin America and the Caribbean: Ways ahead following Accra: FRIDE 2009. http://fride.org/descarga/COM_Sur_Sur3_ENG_mar09.pdf (accessed 11 January 2017).

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

An integrated literature review of undergraduate peer teaching in allied health professions S van Vuuren, BOT, MOT, PhD Health Professions Education School for Allied Health Professions and Department of Occupational Therapy, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: S van Vuuren (alliedhealthfhs@ufs.ac.za)

Background. The concept of peer-assisted teaching or peer-assisted learning (PAL) has been receiving more attention in the teaching of medical and allied health students. Many advantages have been described in the literature, but much more research is needed. Challenges with the academic platform at a specific institution of higher learning necessitate investigation into the current literature on PAL, which can inform decisions in terms of teaching and learning of allied health professions students.

Objective. To critically appraise evidence of the effectiveness and implementation of PAL during the professional clinical skills training of undergraduate students in allied health professions to make informed future decisions on teaching and learning.

Methods. A literature search was conducted by an experienced librarian in the Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa and the researcher in multiple electronic databases (MEDLINE, CINAHL, Africa-Wide Information, ERIC and PubMed) published from 2000 to 2014.

Results. One hundred and seventy-five articles on PAL in health professions training were identified. The selected articles (n=20) were independently critically appraised by two researchers by means of the standardised critical appraisal skills programme (CASP) and the Author Manuscript of the National Institutes of Health on Appraising Quantitative Research in Health Education. Nine articles were identified to be reviewed (two by the same author).

Conclusion. The findings with regard to the limited number of articles reviewed suggested that PAL may address some of the needs of the new generation of students and may be beneficial to the student tutor, student tutee and clinical supervisor. More evidence is needed in terms of the questions arising from the review, especially with regard to occupational therapy, dietetics and nutrition, and optometry, to fully implement PAL. Afr J Health Professions Educ 2017;9(1):9-12. DOI:10.7196/AJHPE.2017.v9i1.588

Allied health professions programmes, in particular with regard to occupational therapy, physiotherapy, and dietetics and nutrition, share common traits in the structure of their clinical programmes. Each requires clinical experience for undergraduate students, which provides valuable hands-on patient care.

From an educational viewpoint, the accreditation standards of the professional bodies and institutions of higher learning, to which the clinical training programmes must adhere, are also applicable. Acquiring these clinical professional skills needs clinical supervisors who must balance patient care with clinical instruction and supervision of students.

One strategy adopted in nursing and medicine to address the teaching of clinical skills is peer-assisted learning (PAL), which is well documented in especially nursing training programmes.[1-3] Informal PAL has been practised for many years among students of all health professions, while formal or planned PAL became particularly prominent in medical education in recent years.[1] PAL is increasingly being implemented in healthcare education for a variety of reasons, i.e. increased student numbers, teaching professional skills in a clinical setting, increasing focus on group training, and challenges with clinical supervision and placements. The literature indicates that in allied health professions PAL is under-researched,[3] a view shared by Sevenhuysen et al.[4] Martin and Edwards[5] added that although the benefits of peer learning have been well documented in the educational literature, it is less so in health professions education. PAL in allied health professions is not as well documented as in medicine and nursing, although common principles are relevant for most

clinical training courses. The terminology used to describe PAL is often submerged under a general label,[2] such as informal teaching by senior students.

For the purpose of this literature review, planned PAL is defined as peer tutoring and peer learning.

Boud[6] describes planned PAL as ‘a two way reciprocal learning activity and should involve the sharing of knowledge, ideas’. Topping[7] added that PAL takes place among people of similar social groupings who are not professional teachers, helping each other to learn and learning themselves by teaching.

Researchers are of the opinion that the benefits of this approach include reinforcement and revision of learning, provision of feedback, role-modelling, communication, appraisal and team-working skills. Curriculum developers also increasingly consider PAL as a vehicle to help undergraduate healthcare students learn to teach.[3] It is further argued that the peer teachers have ‘cognitive congruence’, which allows these tutors to use language that their tutees understand and to explain concepts at an appropriate level.[6,8] In the USA, a recent study of 130 medical schools indicated that 76% use students in some form of PAL, and interest is growing in the field of PAL in medical and allied health professions.[8] The reason for this interest is that PAL can be considered to address gaps in learning after assessment, and new learning outcomes or drivers from external and political requirements. In the UK, the lack of interest among some health professionals to pursue an academic career may be due to limited teaching skills.[1] An article on the clinical education of physiotherapy students adds that the demand for clinical

March 2017, Vol. 9, No. 1 AJHPE

9

Research placements outstrips the supply of facilitators – and PAL can support clinical facilitators.[3] The School for Allied Health Professions (SAHP), University of the Free State, Bloemfontein, South Africa currently offers four undergraduate programmes, i.e. nutrition and dietetics, occupational therapy, physiotherapy, and optometry. Investigation of the possibilities of PAL is necessitated by several factors, such as challenges in terms of the current academic platform for different stages of clinical training, the economic advantages for both the teaching institution and clinical fieldwork areas, enhancing the teaching skills of senior students, role-modelling for junior students, and increased collegial behaviour among different groupings of students. Planned PAL has been implemented as a pilot project in 2013 in the Department of Occupational Therapy as part of revisiting the current undergraduate curriculum and clinical training platforms. Another department is also investi­gating the possibilities to enhance the quality of teaching and learning owing to increased institutional research, other expectations of staff, and challenges with the availability of clinical supervisors in the public health sector. To assume that PAL will add to addressing these challenges, further investigation of the literature is necessary, as the best available evidence will inform/confirm current and future clinical teaching decisions regarding the training programmes in SAHP.

Objective

This integrated literature review was done by the researcher to appraise findings of the effectiveness and implementation of PAL (peer tutoring and peer learning) during the training of undergraduate students in allied health professions in professional clinical skills, contributing to informed future decisions on teaching and learning. The purpose of the literature review was to identify: (i) PAL in allied health profession programmes – professions that adopted PAL and level of students involved; (ii) the dimensions of PAL, which included training of tutors and tutees; formality of teaching encounter; evaluation of tutor and tutee; group size; outcome related to knowledge, skills and attitudes of tutors and tutees; strategies enabling implementation of PAL; and recommendations to improve PAL.[1,2,8]

Methods

A literature search was conducted by an experienced librarian in the Faculty of Health Sciences and the researcher in multiple electronic databases (MEDLINE, CINAHL, Africa-Wide Information, ERIC and PubMed) from 2000 to 2014. The following keywords and phrases were used: peer-assisted teaching health sciences; PAL and undergraduate allied health professions; PAL and occupational therapy; PAL and physiotherapy; PAL and nutrition and dietetics; and PAL and optometry. One hundred and seventy-five articles on peer-assisted learning in health professions training were identified.

The selection criteria for the final review were as follows: • articles on PAL for allied health professions undergraduate students as a group • articles on PAL applicable to undergraduate students in nutrition and dietetics, occupational therapy, optometry and physiotherapy • PAL teaching clinical professional skills • full-text articles published in English • articles of qualitative and quantitative nature • articles related to undergraduate training.

10

March 2017, Vol. 9, No. 1 AJHPE

The selected articles (n=20) were independently critically appraised by two researchers by means of the standardised Critical Appraisal Skills Programme (CASP),[9] and the Author Manuscript of the National Institutes of Health on Appraising Quantitative Research in Health Education.[10] Eight articles were identified to be reviewed. These nine articles referred only to occupational therapy and physiotherapy programmes. No research articles on PAL in nutrition and dietetics or optometry were retrieved. The other 12 articles were excluded as they described blogging and not person-to-person learning; PAL relating to postgraduate students and theory; collaborative learning (group work and problem-based learning); collaborative supervision models that included principles different from those of PAL; PAL in other professional groups; and peer support, mini literature descriptions and collaborative group support.

Ethical approval for the study was obtained from the Faculty of Health Sciences Ethics Committee according to faculty research policy (ref. no.

EUFS 182/2014).

Results

This review was unable to provide conclusive evidence on PAL in allied health professions owing to the small number of relevant articles, lack of articles on nutrition and dietetics and optometry, difference in sample size, study population, and duration of implementation of PAL. The majority of the articles reflected PAL of physiotherapy undergraduate students.

However, the articles reviewed agreed on most of the principles of PAL and can be used to guide the planning and implementation of PAL.

PAL in allied health professions programmes

Two of the articles were related to occupational therapy programmes[11,12] and the remaining six to physiotherapy programmes.[13-18] This indicated that knowledge on PAL in the allied health professions is limited.

The level of students participating in PAL indicated that experienced students mostly help inexperienced ones. Using PAL during the training of professional skills, the tutors and tutees should be senior students,[11,12,18] but PAL could also be implemented during the first year of study in physiotherapy.[14] One article conveyed the opinion that students from the same academic year could also assist.[12] Evidence is needed for occupational therapy, dietetics and nutrition, and optometry to determine at what level of their programmes PAL will be most beneficial.

Dimensions of PAL

In this section the following is addressed: training of tutors and tutees; formality of the teaching encounter; evaluation of tutor and tutee; group size; outcome related to knowledge, skills and attitudes of tutors and tutees; strategies enabling implementation of PAL; and recommendations to improve PAL.

Training of tutors and tutees

Student preparation has frequently been cited as key for a successful PAL experience. Without training the tutors and tutees may not have the skills to make their collaborative relationship work.[13] It is important to be explicit about what peer learning does/does not entail, and what it intends to achieve.[14] A compulsory 2-hour tutorial session on peer coaching was hosted and students had to read an article on PAL in clinical education.[13] In another study an introductory lecture was presented and a hand-out was

Research given that covered information on the structure, aims, benefits, guidance on the roles of tutor and tutee, and what topics should be dealt with during PAL,[14] and also understanding the group process, such as leadership, conflict management, decision-making and adult learning principles.[17] During the preparation sessions, some tutors viewed PAL as positive, while others felt there was nothing to gain by helping fellow students and demonstrated resentment in parting with their own knowledge,[15] or the development of competition that could result in disengagement among students.[16] The literature confirms the importance of adequate preparation of students by instructors and students to accept peer tutors.[13,14,17] Ladyshewsky[16] proposed an eight-step model for the preparation of peer coaching, starting with assessment of compatibility and trust building; planning; formalising the process; defining the goals; clarifying facts and assumptions; exploring possibilities; gaining commitment to actions; offering support; and accountability. Previous research demonstrated that the preparation of students during training is very important and little is known about PAL in the training of other allied health professionals. Research is needed by these professions to establish whether some clinical skills and fieldwork settings are more appropriate for the implementation of PAL; what information should be shared with the clinical supervisors; and/or whether they need any training beforehand.

Formality of the teaching encounter

Planned peer teaching indicates that some formality during the planning and execution of formal encounters should be scheduled. Findings by Hammond et al.[14] showed that PAL sessions should be organised and incorporated in the timetable and curriculum of students, and not be seen as an additional task, but enjoyed as self-directed tutoring sessions.[18] Adequate preparation of those directly involved is necessary, which means that formal sessions for both the tutors and tutees are required and academic oversight should be maintained to ensure consistency and quality of teaching.[17] Students also indicated that they felt that staff should be present at the sessions.[18] Formal PAL has been demonstrated to reduce demands on clinical supervisors and to improve the overall clinical experience of students.[16]

Evaluation of tutor and tutee

Feedback is essential during learning and coaching, and tutors must understand the principles of formative feedback. Ladyshewsky[16] was of the opinion that feedback is difficult to administer in PAL, as it often becomes evaluative and influences the experience. Providing formative feedback through key coaching questions will engage tutees to reflect on their clinical reasoning and practice. This approach preserves the integrity of the relationship and strenghtens it. Where PAL was used for preparation of formative assessment,[15] a student who failed received immediate feedback and further practice time to rectify mistakes. It has been suggested that most student evaluation forms to be completed during clinical work should have a section on professional behaviour, and that PAL of both the tutor and the tutee could be assessed in this section. The following example was given:[16] Competency: Professional behaviour This demonstrates appropriate commitment to learning by: • demonstrating a positive attitude (motivation) towards learning • welcoming/seeking opportunities to gain new knowledge • reviewing appropriate material related to, e.g. the clinical specialty.

Limited research has examined the preferences of tutors and tutees for assessment and feedback. Therefore, it would be helpful to determine if there should be instances where the tutor and tutees are assessed. However, to create an environment conducive to learning for both, the author is of opinion that it should only be part of the formative assessment.

Only two of the articles addressed the specific evaluation during PAL by means of a quantitative and a qualitative research study.[4,13] Both these studies relate to physiotherapy programmes.

Group size

The literature describes a variation in group size of 1:1, 1:2 and 1:3,[11,12,17] although current trends refer to students working in pairs, i.e. a 1:1 learning experience.[6] None of the remaining articles mentioned the group size, but referred to growing confidence of tutees as the session continued, and, taking into consideration that tutees have to master their own clinical skills, a 1:1 group size seems the most realistic.[16]

Outcomes of PAL related to knowledge, skills and attitudes of tutors/tutees Tutors Peer tutoring provides students with opportunities to develop teaching support skills and enables them to function on a higher cognitive level and transfer learning to new situations.[17] These skills are very important for allied health professionals, as in many instances clients are taught new skills, exercises and precautionary measures, to name a few. Understanding the principles of adult learning is also important during professional interventions; PAL creates an opportunity to tutees to apply and practise these principles. Teaching other students has been reported as positive; it also helped to develop their own learning and reasoning.[11-13,18] Added advantages include the promotion of collegial relationships between the students,[17] and facilitating communication skills.[13,18] Asghar[15] indicated that students showed sensitivity and empathy with regard to providing feedback to their peers. Physiotherapy students were also of the opinion that it was an opportunity to revise their skills and even master skills that they had not mastered in previous years of training.[13,18] This approach provides an added bonus for senior students to do revision during clinical placements, as some of the skills were taught in previous years and the full programme does not have sufficient free time for revision. Occupational therapy students reported that they viewed things from a different perspective after the PAL sessions and it increased their confidence in their own skills.[11] The challenges described in the literature are clashes of personalities,[12] negative attitudes of tutors related to the sharing of knowledge,[15] and inconsistency in the level of support given.[11] Tutees Tutees’ experience of PAL has been described as positive. PAL allowed them to focus on learning without fear of asking basic questions and reduced stress.[12,17,18] Some individuals felt more confident approaching a peer leader than a staff member with questions.[18] Many of the effects on the skills, knowledge and attitudes of tutors and tutees are similar, such as the mastery of skills; transfer of learning in the classroom; improvement of communication skills and collegial relationships; and facilitation of clinical reasoning.[11-13,18] Tutees were also of the opinion that the PAL environment had been useful to clarify issues that

March 2017, Vol. 9, No. 1 AJHPE

11

Research they did not understand in the formal teaching sessions, and that it fostered positive attitudes towards the subject matter.[17] Challenges during PAL were congruent with those experienced by tutors, except that advanced students might dominate the learning environment or competition between tutee and tutor might occur. With no regulation of the content of the sessions, the potential exists for incorrect information to be conveyed.[18] The cohort of students in health sciences are competitive by nature. It should, however, be stressed that competition is frowned upon in the current clinical practice environment, and working together as a team is necessary for today’s health professionals, which should be emphasised during this learning experience.[16]

Strategies enabling implementation of PAL

Although most articles elucidated the experiences and value of PAL, only one article gave a more detailed overview of the process of implementation.[16] Aspects to address during implementation are facilitation of a positive interdependence between tutors and tutees; preparation of tutors in understanding adult learning principles and group processes, such as leadership, conflict management, decision-making, giving feedback, how to deliver information in a non-evaluative manner; and reflection on and evaluation of processes. Individual accountability should be fostered in both the tutor and tutee. The same article[16] described the different stages and objectives in each stage of implementation.

Other findings with regard to implementation included compilation of a hand-out for PAL,[11] careful incorporation of time in the timetable and curriculum to train and orientate the tutors and tutees,[14] collaboration of students in the writing of pre-placement packs,[12] putting a control system of qualified professionals in place to ensure consistency of dissemination of information, and ensuring a mechanism for debriefing peer tutors and to clarify queries.[17]

Recommendations to improve PAL

Asking two people to coach each other does not necessarily guarantee success. Although all 175 articles reported on the value of PAL, more evidence-based practice and research are needed to promote tailor-made PAL for a specific programme. Questions still unanswered, according to the literature, include how learning is negotiated within PAL sessions, and whether PAL promotes informal group activities outside the classroom.

Ongoing investment in student support will be needed and, in addition, strategies (social media such as blogs and Facebook) must be investigated to provide equivalent support to students in clinical placements outside the city to ensure parity across the whole student group.[11,14,16] Limited literature on the implementation of PAL in occupational therapy and other allied health professions warrants more research about the planning and implementation of PAL for these programmes. Although deemed a positive learning strategy in nursing and medicine with more researched evidence available, allied health professions need their own evidence to inform their decisions on clinical teaching.

12

March 2017, Vol. 9, No. 1 AJHPE

Conclusion

Since 2000, little has been published on occupational therapy, dietetics and nutrition, and optometry. Physiotherapy has investigated PAL slightly more often, but most of the research was grounded in the work of one researcher at a specific institution of higher learning. This limited literature acknowledges the need for more research on the topic, as the majority of findings in other health professions[1,2,4-6] and the reviewed articles indicate that the value for staff, clinical placements and students’ positive experiences outweigh the challenges.

Insufficient clinical placements and supervision for undergraduate students in occupational therapy, physiotherapy and other allied health professions, as well as sufficient time for staff in higher education to adhere to their different roles, are a reality in the South African context. Globally, there is a need for more innovative methods to teach professional skills to health professionals, in addition to the need and requirements to also give attention to other skills, such as leadership, communication skills and clinical reasoning.

The findings in the limited number of articles reviewed show that PAL may address some of the needs of the new generation of students and may be beneficial for the student tutor, student tutee and clinical supervisor. More evidence on the questions that arise from the review, especially with regard to occupational therapy, dietetics and nutrition, and optometry, is needed to fully implement PAL.

1. Ross MT, Cameron HS. Peer assisted learning: A planning and implementation framework. AMEE Guide No. 30.

Med Teach 2007;29(6):527-545. http://dx.doi.org/10.1080/01421590701665886 2. Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: A novel approach to clinical skills learning for medical students. Med Educ 2007;41(4):411-418. http://dx.doi.org/10.1111/j.1365-2929.2007.02713.x 3. Secomb J. A systematic review of peer teaching and learning in clinical education. J Clin Nurs 2008;17(6):703716. http://dx.doi.org/10.1111/j.1365-2702.2007.01954.x 4. Sevenhuysen SL, Nickson W, Farlie MK, Raitman L, Keating JL. The development of a peer assisted learning model for the clinical education of physiotherapy students. J Peer Learn 2013;6:30-45. http://ro.uow.edu.au/cgi/ viewcontent.cgi?article=1068&context=ajpl (accessed 15 January 2015).

5. Martin M, Edwards L. Peer learning on fieldwork placements. Br J Occupational Ther 1998;61(6):249-252. http:// dx.doi.org/10.1177/030802269806100603 6. Boud D. Introduction: Making a move to peer learning. In: Boud D, Cohen R, Sampson J, eds. Peer Learning in Higher Education: Learning from Each Other. London: Kogan Page, 2001:1-20.

7. Topping KJ. The effectiveness of peer tutoring in further and higher education: A typology and review of the literature. High Educ 1996;32:321-345. http://dx.doi.org/10.1007/BF00138870 8. Burgess A, McGregor D, Mellis C. Medical students as peer tutors: A systematic review. BMC Med Educ 2014;14:115. http://dx.doi.org/10.1186/1472-6920-14-115 9. Maden-Jenkins M. CASP 2006. Literature Searching for Qualitative Studies and Quality Appraisal. Lancashire, UK: Edge Hill University, 2006.

10. Jack L Jr, Hayes SC, Scharalda JG, et al. Appraising quantitative research in health education: Guidelines for public health educators. Health Promotion Practice 2010;11(2):161-165. http://dx.doi.org/10.1177/1524839909353023 11. Daniels N. Peer interactions and their benefits during occupational therapy practice placement education.

Br J Occupational Ther 2010;73(1):21-28. http://dx.doi.org/10.4276/030802210X12629548272664 12. Steele-Smith S, Amstrong M. 'I would take more students but…’: Student supervision strategies. Br J Occupational Ther 2001;64(11):549-551.

13. Ladyshewsky RK. A quasi-experimental study of the differences in performance and clinical reasoning using individual learning versus reciprocal peer coaching. Physiother Theory Pract 2002;18(1):17-31. http://dx.doi. org/10.1080/095939802753570666 14. Hammond JA, Bitchell CP, Jones L, Bidgood P. A first year experience of student-directed peer-assisted learning.

Active Learn High Educ 2010;11(3):201-212. http://dx.doi.org/10.1177/1469787410379683 15. Asghar A. Reciprocal peer coaching and its use as a formative strategy for first-year students. Assess Eval High Educ 2010;35(4):403-417. http://dx.doi.org/10.1080/02602930902862834 16. Ladyshewsky RK. Building co-operation in peer coaching relationships: Understanding the relationships between reward structure, learner preparedness, coaching skill and learner engagement. Physiotherapy 2006;92(1):4-10. http://dx.doi.org/10.1016/j.physio.2005.11.005 17. Lekkas P, Larsen T, Kumar S, et al. No model of clinical education for physiotherapy students is superior to another: A systematic review. Aust J Physiother 2007;53(1):19-28. http://dx.doi.org/10.1016/S0004-9514(07)70058-2 18. Sole G, Rose A, Bennet T, Jaques K, Rippon Z. A student experience of peer assisted study sessions in physiotherapy. J Peer Learn 2012;5:42-51. http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1042&context=ajpl (accessed 6 January 2016).

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Developing a service-learning module for oral health: A needs assessment R Ebrahim,1 MSc (Dent); H Julie,2 MPH, MCur, PhD 1

Extended Programme, Faculty of Natural and Agricultural Sciences, University of Pretoria, South Africa

2

School of Nursing, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa

Corresponding author: R Ebrahim (ruebecca.ebrahim@up.ac.za)

Background. Service learning (SL) as a pedagogy in higher education must be differentiated from other services with a primarily philanthropic intent.

Dental therapy and oral hygiene students at Sefako Makgatho Health Sciences University, School of Oral Health Sciences, Pretoria, South Africa visit community sites during their 2nd year of study. However, the current curricula would need restructuring for alignment with the espoused pedagogy and standards of SL. Such an SL curriculum design would thus allow for the provision of meaningful services to communities as an integral component of these programmes.

Objective. To explore (i) perceptions of 2nd-year oral health students; and (ii) opinions of academics with regard to the need for an SL module.

Methods. Purposive sampling was used to conduct two focus group discussions with academics involved in curriculum development (n=11) and students who had previous exposure to communities (n=10). A survey containing open-ended questions was completed by 9 academics, who would implement the proposed SL module. Frequencies were calculated and data from the open questions were analysed for emergent themes.

Results. Most academics (89%, n=8) indicated that working effectively with others as members of a team and developing cultural sensitivity were achievable from an SL module. Two themes emerged from the focus groups, i.e. (i) enhanced teaching and learning – students could apply theoretical and clinical training in an authentic setting; and (ii) standardisation of training – an SL module would ensure consistency when engaging with communities.

Conclusion. The needs assessment was valuable to inform the development and implementation of the SL module.

Afr J Health Professions Educ 2017;9(1):13-16. DOI:10.7196/AJHPE.2017.v9i1.597

Proponents of service learning (SL) state that it is a form of experiential education that combines student learning goals intentionally with service provision to communities.[1-4] The rationale for these SL activities is grounded in educational philosophies that propagate social responsibility as the primary goal of learning.[5] Educators who integrate SL into the curriculum hope to develop cultural sensitivity and civic responsibility in students by raising student awareness with regard to the challenges communities experience. This philosophical stance is also reflected in SL definitions formulated by acclaimed US scholars, such as Bringle and Hatcher,[2] and in South African (SA) higher education policy documents.

Bringle and Hatcher[2] define SL as a ‘course-based, credit-bearing educational experience in which students participate in an organised service activity that meets the identified community needs and reflect on the service activity in such a way to gain further understanding of the course content, a broader appreciation of the discipline and an enhanced sense of personal values and civic responsibility’.

In the SA context, the Higher Education Quality Committee (HEQC) positioned SL as a core function of higher education to advance social development and transformation of disadvantaged communities.[3] To this end, the HEQC has formulated criteria for SL as Criterion 7 in the Framework for Institutional Audits[6] and in the Framework for Programme Accreditation.[7] In addition, SL provides an opportunity for the students to reflect on the service activity in such a way as to gain further understanding of the course

content, a broader appreciation of the discipline, and an enhanced sense of civic responsibility. This is achieved through the introduction of reflection as an assessment strategy. According to Elyer and Giles,[8] reflection has been identified as a foundational principle of SL and is regarded as the glue that holds service and learning together to provide an optimal educative experience.

Reflective practice is about acquiring the skills and attitude to inquire continually into one’s own professional practice and into the context in which it is embedded. It can also take place on different levels to which students are exposed in academic practices. Bringle and Hatcher, as cited

by Julie et al.,[9] state that SL provides higher education institutions with a strategy to explore ways of incorporating service to extend their mission, enhance student achievement, and engage students in their communities as part of their academic curriculum.

Problem statement

Students of Dental Therapy and Oral Hygiene, School of Oral Health Sciences, Sefako Makgatho Health Sciences University (formerly University of Limpopo, Medunsa Campus), Pretoria, SA are trained in predominantly clinical settings. However, these clinical placements are not linked to learning outcomes aimed at developing social responsiveness in the students. Likewise, the community site visits for 2nd-year students are not explicitly linked to their learning outcomes – these visits tend to happen randomly.

March 2017, Vol. 9, No. 1 AJHPE

13

Research Why a needs assessment?

For SL to be institutionalised, standardised and formally structured, an SL component in the curriculum is required. To plan and implement an SL module that will integrate learning in the classroom with practice in the community, it is important to conduct a needs assessment. Research has shown that educational activities based on learning needs are more effective in delivering sustainable educational outcomes for participants; therefore, a learning needs assessment should be conducted as the first step in planning an educational activity.[10] The purpose of designing such a module in oral health would be to integrate classroom teaching with meaningful community service activities, designed as an integral feature of the clinical programme. The objectives were to explore: (i) perceptions of 2nd-year oral health students with regard to the need for a structured module for SL; and (ii) opinions of the academics at the School of Oral Health Sciences, Sefako Makgatho Health Sciences University regarding the need for an SL module.

Definition of terms

• SL is a course-based, credit-bearing educational experience in which students participate in an organised service activity that meets the identified community needs and reflect on the service activity in such a way as to gain further understanding of the course content, a broader appreciation of the discipline and an enhanced sense of personal values and civic responsibility.[4] • Community engagement refers to the interactions and processes through which the expertise of the institution in the areas of teaching, learning and research is applied to develop and sustain society.[5]

Methods

Study setting

The University of Limpopo’s policy on community engagement (CE) identifies SL modules as one of the mandated community engagement activities.[11] The School of Oral Health Sciences, situated in Garankuwa, Pretoria, comprises the departments of Periodontology, Oral Medicine and Community Dentistry; Maxillo-Facial Surgery, Pathology, Radiology and Orthodontics; and Restorative Dentistry, Integrated Clinical Dentistry and Prosthodontics. At the time of the study, three academic programmes were offered, i.e. Bachelor of Dental Science, Bachelor of Dental Therapy, and Diploma in Oral Hygiene. Not all the aforementioned departments, and therefore not all the academics, are involved in the teaching and training of dental therapy and oral hygiene students, as the scope of their clinical practice is limited compared with that of Bachelor of Dentistry students.

Study design

The study used an exploratory descriptive design comprising two focus group discussions with academics and students, respectively, and a quantitative survey with academics.

Population and sample

The study population for the qualitative part was selected based on their potential participation in CE activities. Purposive sampling was used to select the participants for the two focus group discussions. The first focus group comprised 10 3rd-year Bachelor of Dental Therapy students who had participated in unstructured CE activities during their 2nd year of study.

14

March 2017, Vol. 9, No. 1 AJHPE

The second focus group comprised 11 academics who were involved in the teaching and training of the abovementioned students and served on the Curriculum Development Committee (CDC); they were therefore involved in curriculum development at the School of Oral Health Sciences, University of Limpopo Medunsa Campus (currently Sefako Makgatho Health Sciences University).

The study population for the survey comprised an additional 12 academics involved in teaching and training, who were not members of the CDC. Allinclusive sampling was used because these 12 academics were involved in the teaching and training of the abovementioned students and hence were potential implementers of the proposed SL module.

Data collection method and process

Prior to commencement of the study, ethical approval was granted by the School Research and Ethics Committee and the Medunsa Research and Ethics Committee (ref. no. MREC/E/112/2013:PG). Informed consent was obtained from participants, who were assured of confidentiality and anonymity.

The focus group discussions with the academics and students explored the participants’ understanding of SL, how to structure an SL module and how to identify critical cross-field outcomes that could be attained from an SL module. In addition to these questions, in the focus group discussions the researcher also explored the students’ expectations of an SL module.

The focus group discussions were audio recorded, transcribed verbatim and analysed to identify emergent themes. An independent coder validated the findings for correctness after the participants had verified the accuracy of the transcribed data through member checking.

The self-developed structured questionnaire comprising three openended questions explored: (i) the academics’ understanding of SL; (ii) critical cross-field outcomes; and (iii) learning outcomes that could potentially be achieved by introducing an SL module in Dental Therapy and Oral Hygiene.

The frequencies were calculated in Microsoft Excel (USA) for the nine completed questionnaire received, representing a response rate of 75%.

Results

The results of the survey are presented first, followed by the themes that were identified from the two focus group discussions.

Survey results

The major categories identified from the open-ended questions related to: (i) academics’ understanding of SL; (ii) critical cross-field outcomes; and (iii) potential of an SL module to enhance teaching and learning.

Academics’ understanding of SL The exploration of this theme reflected that 55% (n=5) of academics regarded SL as a ‘method of teaching’, while 33% (n=3) stated that SL is ‘rendering service to the community’. Other responses varied from ‘learning while rendering a community service’ to ‘combines cognitive learning with practice’.

Critical cross-field outcomes Fig. 1 illustrates unanimity among all participants (100%, n=9) that the following two learning outcomes could be achieved: ‘identify and solve problems by using critical and creative thinking’ and ‘diagnose, plan and

Research

us tif Id Academics' responses, % ing y a us entif cri ndAcademics' responses, % ing y a tic so cri nd a l a lve tic so nd pr al lve an p cre obl d c ro mWor ati em Wo rea blee k e ve s b ff me rk e toivrg mm thi y e ta s bbyer ecti org mb ffec nk hninis s o ve ing an ers tiv kainti f a ly w isa of ely gon te ith tio a w or am o n o tea ith O t r co , g he O r c m, aothga mm rou rs om grond er ni an rgan maun up ons asse a un p, as an d on ise ndit e , e's nd d e e' an it y d ff y s ffe ac m ec act ma cti tiv an tiv ivi na ve iti ag ely tie ge ly es e C s Co res onol res on cri llec pcori esleec po ese tic t, a ntsic lf t, a ns lf ally na ibal ll n ibl y y e aly ev lysCe y Co alu ,oo va se, ma mm lua or rgm ate m m a the un atihn nuis te gan i c ma at feom inf is rm neicaan orm e a tic e e aatiti tde al ffe coan eff ati nd an ct l a ec on d l ive nd tiv an ly gu us e l an ly ag ing U gu us e s vUi i a n eff se sc ge g kill ssue ec ien esff asl,c ski visu tiv ce ec ien lls al ely a , tiv ce an nd ely a d c tec an nd riti hn Be t d c o e c allyB log se u cri ch tic no e y so nsiti ltura cia ve lly ally log s c l co ac an s ens ultu y nte ross d a ocia itive rally xts a r esth l c ac an an et on ro d ge ica te ss ae of lly xts a ra sth e

120 100 80 60 40

20 120

Id e

n

ng tic e o all f y

0 100 80 60 40 20 0

100 80

The participants’ voices are captured in Table 1. Two themes emerged from the focus groups, i.e. (i) enhanced teaching and learning – students could apply theoretical and clinical training in an authentic setting; and (ii) standardisation of training – an SL module would ensure consistency when engaging with communities. Academic staff and students concurred that students should consult with members of the community before and after the SL activity to identify needs and expectations and obtain feedback.

Enhanced teaching and learning The academics suggested that an SL module would ‘enhance learning if structured for the reciprocity of needs’. While some academics voiced the opinion that SL offers a learning experience in an authentic setting and allows students to ‘look at patients as a whole’, the students discussed how ‘you get to see different things out there that you don’t see in hospitals’, which provides experience in a real-world setting and often requires students to improvise.

120

60

100

40

80

20 60

Ga

the

ra

nd

an

Ga

aly

the

se

ra

da

ta

nd

an

aly

0

me y s

da

20

Ide Ide n tar ntify targ tify ge t t t p he et p he n op ne op ula eds ula eeds tio of tio ng a n g of a rou rou Dia p Dia p a c gno a g om se co nos mu , pla mm e, p nit n a un lan y-b nd it ase im y-b and d p ple ase imp rog me d p le Co ram nt rog me ram nt me an mpa Co d f rea mp me ea nthd sib e fee are ilit ffaes the y o cibt f d iivliet effe en nyeo ct tal sfs,d ive pro eeffin ne gra ctiaeln ss, mm pcryo effi es gra cien m c

ta

0 40

se

Academics' responses, %

Academics' responses, %

Fig. 1. Academics’ responses to critical cross-field outcomes that may be achieved from an120 SL module.

Results emanating from the two focus group discussions

Fig. 2. Academics’ responses with regard to learning outcomes that may be achieved from an SL module.

implement a community-based programme’. They further indicated that ‘work effectively with others as members of a team’ and developing ‘cultural sensitivity’ were also achievable from such an SL module (89%, n=8).

It was also mentioned that ‘interacting and engaging with the community’ would help students to identify the needs of a target population group (78%, n=7).

Potential of an SL module to enhance teaching and learning The overall responses of academics indicated that an SL module would ‘enhance teaching and learning’ (89%, n=8). Responses indicated that an SL module would provide a tool for the site visit; would encourage critical thinking; and that reflection and evaluations would help students to identify strengths and weaknesses and thus enhance learning. The academics also indicated that going out into the community allows students to apply their theoretical knowledge and clinical skills in an environment that differs from the ideal conditions of training institutions. Fig. 2 summarises the academics’ responses regarding learning outcomes that may be achieved from an SL module.

Standardisation of training The students felt that an SL module would provide standardisation of training, allowing them to ‘perform better’, as ‘we have an idea of what we are going to do’.

Students’ statements, ‘learning in the process of helping the community’ and ‘I think it’s also about teaching the community’, indicated that interaction with the community is a two-way learning process.

One student articulated: ‘We have to know what the community needs, because different communities need different treatment.’ The following observation from the student succinctly summarises the essence of SL in terms of service delivery: ‘With SL there is no imposition, it’s a two-way stream, we go there to learn and they receive service from us, and it’s the service they want, not the service we want to give whether they want it or Table 1. Themes and supporting statements Enhanced teaching and learning ‘A learning experience in an authentic setting.’

‘Interaction with the community is a two-way learning process.’

‘Consideration of community expectations.’

‘You get to see different things out there that you don’t see in hospitals.’

‘We have to know what the community needs, because different communities need different treatment.’

‘When we go into a community the people are actually learning, it’s not just service rendering.’

‘You learning in the process of helping the community.’

‘It’s an opportunity to see more cases.’

Standardisation of training ‘You’ll know what to do when you are there.’

‘We have an idea of what we are going to do.’

‘It has to be comprehensive.’

‘People are gonna perform better.’

‘Maybe you’ll find that the other group did certain things that the other group didn’t do.’

‘People at school A are gonna benefit in a way that people at school B didn’t benefit because the people at school B didn’t do it.’

‘Some people, they not doing things – but if it’s in a course then … .’

‘So it becomes more uniformed and structured.’

March 2017, Vol. 9, No. 1 AJHPE

15

Research not.’ The academics also agreed that community needs and expectations are often forgotten, and it is important to determine the community’s values and needs from service providers. This may be achieved by obtaining feedback from the community.

They also saw great value in a multidisciplinary module that could be used by all health professionals, illustrated by the following statements: ‘The best way would be an integrated module, not an oral health module’, and ‘… a comprehensive health module that can be used throughout the Medunsa campus.’

Discussion

Although the University of Limpopo had a policy on community engagement that was approved by the Senate in 2008, all the study participants were unaware of its existence. This could explain the differences in the understanding of SL. Recommendation 33 of the HEQC report[12] suggests that the University of Limpopo ‘(1) conduct an institution-wide debate on what community engagement means for the University; (2) develop a framework document that conceptualises community engagement in relation to the core functions of teaching and learning and research; and (3) put in place strategies and mechanisms to monitor and harness the impact of community engagement initiatives on the core functions of the institution’. This further indicates the need for SL to be formally embedded in the curriculum to ensure that teaching and training are in keeping with the national policy for higher education institutions and the University of Limpopo’s policy on community engagement. Julie et al.[13] reported similar findings at other higher education institutions in SA. This study indicates that SL means different things to different people.

Some academics were aware that SL involves teaching students while addressing identified community needs, while others knew that SL is pedagogy in health education that combines cognitive learning with practice in the community. It is therefore imperative that academic staff are equipped and developed to provide training to students, as SL is first and foremost an academic endeavour requiring the expertise of academic staff, which provides the essential context linking community service to theoretical texts and principles.[1] Students’ understanding of SL was based on their experiences of learning in the process of visiting and helping the community. Many failed to mention the significance of reflection in providing a better understanding of the course content and the impact of social, cultural and economic factors on health. It is important to include reflection in the SL framework for dental education, as reflection is a central characteristic of SL and has been called the hyphen that links service and learning.[14] Yoder[14] states that some of the most powerful learning experiences occur in a non-clinical setting, where the artificial barriers of the white coat do not interfere with communication. The responses from some academics, indicating that an SL module would provide a tool for the site visit, encourage critical thinking and thus enhance learning, validate this

16

March 2017, Vol. 9, No. 1 AJHPE

statement. Developing a module that incorporates SL in the oral health curriculum will allow students to apply the course content to real-world situations, which often lack the resources available at training institutions.

Research has shown that courses incorporating SL components generally provide greater learning benefits than those that do not, including a deeper understanding of course material, a better understanding of the complex problems people face, and an ability to apply course material to new situations.[10] A limitation to the results of this study should be noted. Choosing a survey for the quantitative is a limitation because the results cannot be generalised.

The findings of this study indicate that an SL component in the oral health module will enhance teaching and learning. A further study to develop a framework for the module is recommended.

Conclusion

The findings of this study indicate that an SL module would enhance teaching and learning and would impact on civic responsibility and students’ retention of theoretical and practical course material. Exposure and experiences during a curriculum-integrated module would afford students the opportunity to work in a structured manner, while being guided through the dynamics of authentic settings.

Acknowledgements. The authors gratefully acknowledge the following from the University of Limpopo Medunsa Campus (currently Sefako Makgatho Health Sciences University): the CDC members and 3rd-year dental therapy students for their willingness to participate in the focus group discussions; Drs A Khan, N Nzima, and P Motloba, and Prof. T Gugushe for their assistance, and Prof. G Ogunbanjo for his feedback. The authors also acknowledge the Sub-Saharan Africa-FAIMER Regional Institute (SAFRI) for the invaluable mentorship support.

1. Bender CJG, Daniels P, Lazarus J, Naude L, Sattar K. Service Learning in the Curriculum: A Resource for Higher Education Institutions. Pretoria: Council on Higher Education and Jet/CHESP, 2006:40-46.

2. Bringle RG, Hatcher JA. A service-learning curriculum for faculty. Michigan J Comm Serv Learn 1993;(2):112-122.

3. Higher Education Quality Committee. Service Partnerships. Service Learning in the Curriculum: A Resource for Higher Education Institutions. Pretoria: Council on Higher Education, 2006.

4. Hood JG. Service-learning in dental education: Meeting needs and challenges. J Dent Educ 2009;73(4):454-463.

5. Osman R, Petersen N. Students’ engagement with engagement: The case of teacher education students in higher education in South Africa. Br J Educ Studies 2010;58(4):407-419. http://dx.doi.org/10.1080/00071005.2010.527665 6. Higher Education Quality Committee. Framework for Institutional Audits. Pretoria: Council on Higher Education, 2004.

7. Higher Education Quality Committee. Framework for Programme Accreditation. Pretoria: Council on Higher Education, 2004.

8. Elyer J, Giles DW. Where’s the Learning in Service-learning? San Francisco: Jossey-Bass, 1999.

9. Julie H, Daniels P, Adonis TA. Service-learning in nursing: Integrating student learning and community-based service experience through reflective practice. Health SA Gesondheid 2005;10(4):41-54. http://dx.doi.org/10.4102/ hsag.v10i4.206 10. Association of Reproductive Health Professionals. Conducting a CME activity needs assessment. 2002. http://arhp. org/about-us/joint-sponsorship/needs-assessment (accessed 27 January 2017).

11. University of Limpopo. Community Engagement Policy. Pretoria: UL, 2008:5. https://ul.ac.za/application/.../ COMMUNITY%20ENGAGEMENT%20POLICY (accessed 3 February 2017).

12. Council on Higher Education.Higher Education Quality Committee. Report to the University of Limpopo.

Executive Summary. Pretoria: CHE, 2011. http://www.che.ac.za/sites/default/files/institutional_audits/institutional_ audits_2010_lp_executive_summary.pdfwww.che.ac.za/.../institutional_audits_2010_lp_executive_summary (accessed 3 February 2017).

13. Julie H, Adejumo OA, Frantz JM. Cracking the nut of service-learning in nursing at a higher educational institution.

Curationis 2015;38(1). http://dx.doi.org/10.4102/curationis.v38i1.117 14. Yoder KM. A framework for service-learning in dental education: Meeting needs and challenges. J Dent Educ 2006;70(2):115-123.

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Barriers to continuous professional development participation for radiographers in Kenya L G Kanamu,1 MTech Rad, BTech Rad (D), HDip Med Ed, Dip Rad (D); B van Dyk,2 MTech Rad, BTech Rad (U/S), NDip Rad (T), NDip Rad (D); L Chipeya,2 MPhil HE, BAdmin Hons Ind Psych, BAdmin, NHD (NM), NDip Rad (D & NM); S N Kilaha,3 PhD, MMed Ed, HDip Med Ed, Dip Rad (D) 1

Department of Medical Imaging Sciences, Faculty of Diagnostic Sciences, Kenya Medical Training College, Nairobi Campus, Kenya

2

Department of Medical Imaging and Radiation Sciences, Faculty of Health Sciences, University of Johannesburg, South Africa

3

Department of Medical Imaging Sciences, Faculty of Diagnostic Sciences, Kenya Medical Training College, Nyeri Campus, Kenya

Corresponding author: B van Dyk (bvandyk@uj.ac.za)

Background. Updating knowledge and skills on an ongoing basis is an important requirement if one is to remain professionally relevant. Formalised continuous professional development (CPD) is, therefore, essential to stay up to date in a dynamic work environment. The majority of radiographers in Kenya work in remote rural health facilities, where CPD activities are limited. The question therefore arose: ‘To what extent are radiographers participating in CPD activities and what constitute barriers to participation?’

Objective. To describe the challenges that affect diagnostic radiographers’ participation in CPD activities in Kenya.

Methods. The study targeted radiographers who were registered with the Society of Radiography in Kenya (SORK). Two hundred and fifty prospective participants were recruited from the SORK database, using the fish-bowl sampling method. Questionnaires with self-addressed stamped envelopes were posted by ordinary mail to facilitate ease of return, while telephonic follow-up improved the response rate.

Results. The study revealed that 69% of diagnostic radiographers in Kenya were effectively participating in CPD activities. Barriers to CPD participation included time constraints (62%), financial constraints (66%), lack of information (54%), organisational culture (47%), paucity of resources (58%), and difficulty in being selected by their organisation to attend CPD activities (42%).

Conclusion. Professional development in a rapidly developing and expanding profession such as radiography is critical for best practice. Although the majority of diagnostic radiographers in Kenya participate in CPD, a large number do not owing to various challenges. A lack of finances was one of the most significant factors that served as a barrier. SORK, employers and institutions of higher education all have a responsibility towards the culture of lifelong learning. As the professional organisation representing radiographers, SORK should engage all stakeholders to collectively address the barriers to CPD participation for radiographers in Kenya.

Afr J Health Professions Educ 2017;9(1):17-20. DOI:10.7196/AJHPE.2017.v9i1.605

Obtaining a professional qualification can be viewed as a starting point that demonstrates the minimum level of competence within a given field of study.[1] The half-life of knowledge varies between 2 and 5 years. Therefore, knowledge obtained at the point of professional qualification is insufficient to support an individual throughout a lifetime of professional practice.

New learning opportunities that translate into advanced professional competencies should hence be created.[2] Professional practitioners should consequently improve their knowledge and skills to stay abreast and meet the demands of the dynamic environment in which they operate.

Continuous professional development (CPD) evolved from the need for a platform that allows professionals to become lifelong learners and stay up to date with new knowledge, developments and skills. CPD can be defined as ‘the continuous and systematic maintenance, improvement and broadening of knowledge, expertise and skills for the execution of professional duties throughout the practitioners’ working life’.[3] CPD is, therefore, an ongoing process, encompassing formal and informal education, which builds on an initial professional qualification and addresses the learning needs of practitioners in preparation for new responsibilities or extended roles.

After the implementation in 2004 of compulsory CPD for Kenyan health professionals, the Society of Radiography in Kenya (SORK) established CPD

guidelines for radiography, in which they undertook to: • ensure that CPD addresses the short-term learning needs of radiographers, while maintaining high competence standards for the profession in the longer term • encourage radiographers to participate in CPD by providing a systematic framework that supports lifelong learning • accredit all CPD activities • promote CPD by working in partnership with employers, academic institutions, government agencies and other relevant bodies.

The current CPD requirement for radiographers in Kenya is based on the attainment of 40 credits obtained over a 2-year cycle. Numerous factors may influence CPD participation among members of a profession. These factors can include professional attitude, work pressure, job satisfaction, organisational culture, dissemination of information, financial or time constraints, or lack of resources, including access to journals or other educational materials. Some of these factors are especially detrimental to professionals in rural and remote work environments.[4] As the majority of radiographers (63.6%) work in rural and remote health facilities in Kenya, this study was conducted to investigate the barriers experienced by diagnostic radiographers to CPD participation.

March 2017, Vol. 9, No. 1 AJHPE

17

Research

Table 1. Overall participation in CPD activities

18

March 2017, Vol. 9, No. 1 AJHPE

59 (36) 103 (64)

60 40 20

n No

m

ina

tio

ur e Cu lt

ati

on

0

nc e

Participants were safeguarded against ethical misconduct by obtaining permission to collect data from the National Council for Science and Technology (NCST/5/002/R/537/5) in the Ministry of Higher Education, Science and Technology of the government of Kenya. The research was further approved by the Higher Degrees and Research Ethics Committees of the University of Johannesburg, South Africa (ref. no. HDC 40/2009). A letter explaining the purpose of the study and giving assurance of anonymity and voluntary participation, accompanied the questionnaires.

112 (69) 49 (30) 1 (1)

80

Fin a

Ethical considerations

n (%)

Category Are you enrolled in a CPD programme (N=162)?

Yes No No response Do you work in a rural or urban setting (N=162)?

Urban Rural

%

Data analysis was performed using SPSS version 14.0 (SPSS Inc., USA).

While descriptive analysis aimed to describe the sample and summarise variables, cross tabulations were employed to demonstrate relationships between variables. Pearson’s χ2 test was likewise employed to compare variances between categorical data in non-2 × 2 tables, followed by Cramér’s V test, used as a post test to determine the strength of the association, with a value between 0 and 1. (Low association <0.3; moderate association 0.3 - 0.5; high association >0.50.)[6] A p-value of <0.05 indicated that a relationship exists between two variables and the null hypothesis was rejected.

Knowledge and skills become obsolete in the absence of efforts to update them on an ongoing basis.[7] However, this study found that diagnostic

m

Statistical analysis

Discussion

Inf or

The dependent variable was defined as CPD participation, while the independent variables consisted of a number of factors with the ability to influence participation rate, as identified from the literature.[4] Data were collected with the aid of a self-administered questionnaire.

Content validity of the questionnaire was addressed by providing a set of questions as derived by an extensive literature review.[4] External consistency was pretested by subjecting the questionnaire to a pilot study, allowing for information that was not clearly understood to be addressed before data collection commenced. The pilot study thus measured the reliability of the instrument.

Questionnaires, including an explanatory letter, were mailed to prospective participants with a stamped self-addressed envelope to facilitate ease of return. Questionnaire items targeted information regarding barriers to CPD participation, while questionnaires were completed anonymously.

ur ce s

Data collection

so

The population comprised ~1 000 diagnostic radiographers, who were registered as members of SORK at the time of the study. To calculate the sample size, a confidence level of 95% with a confidence interval (CI) of 5% was set by using the following formula: N=P (100% − P)/(SE)2. (N = calculated sample size (296); P = proportion of radiographers (74%) expected to participate in CPD activities, as derived from responses in the pilot study (N=19); SE = standard error, calculated by dividing the CI by 1.96 (5/1.96=2.55).)[5] A calculated sample size of 296 participants was ideal, but owing to financial constraints, only 250 questionnaires were dispatched to radiographers, who were randomly selected from the SORK database, using the fish-bowl technique.[6]

Of the 250 questionnaires, 162 (65%) were returned and available for analysis. Table 1 indicates that just over two-thirds (69%) of diagnostic radiographers, registered with SORK, were enrolled in a CPD programme.

Factors influencing CPD participation in the Kenyan context are displayed in Fig. 1. Financial constraints, time constraints and a paucity of resources were rated as the most significant barriers to CPD participation among radiographers.

Tables 2 and 3 show the extent to which each of the factors in Fig. 1 affected participation in CPD activities. The factors indicate the options selected by each participant in response to a Likert scale.

The lack of finances, as indicated in Table 3, mostly affected participants’ involvement in formal training programmes (p=0.017; Cramér’s V=0.302), the acquisition of (p=0.048; phi=0.267) and reading (p=0.036; Cramér’s V=0.258) of scientific journals.

Although time constraints (p=0.576), organisational culture (p=0.341), availability of resources (p=0.46) and difficulty in getting nominated/ selected by the organisation to attend CPD activities (p=0.226) affected CPD participation to some extent, these factors showed no statistical significance.

Dissemination of CPD information to SORK members appeared to be the least significant barrier. However, statistical significance with a weak association was recorded between communication from SORK to its members and the regularity with which seminars or workshops were attended.

e

Population and sampling

Results

Re

This was an empirical study; it therefore relied on perceptions, experiences and observations of participants. A quantitative descriptive survey allowed for the statistical comparison between variables.

Tim

Methods

Fig. 1. Barriers to CPD participation among diagnostic radiographers in Kenya.

Research

Table 2. Barriers to CPD participation (N=162) Scale used to rate the extent to which CPD participation is affected by each factor Not affected (0) Least extent (minimal chance) (1) Some extent (some chance) (2) Great extent (3) No response Total

Financial constraints, % 3 7 25 34 31 100

Time constraints, % 7 9 30 23 31 100

Paucity of resources, % 7 12 29 17 35 100

Table 3. Cross tabulations between barriers and CPD participation (N=112) Test

Value

p-value

Effect of financial constraints on CPD participation 1. Were you enrolled in any formal training programme in the last 12 months?

Pearson’s χ2 10.240 Cramér’s V 2. How often do you read scientific journals?

Pearson’s χ2 Cramér’s V 3. Do you subscribe to scientific journals?

Pearson’s χ2 Cramér’s V

0.017

0.302

Moderate association

22.117

0.036

0.258

Weak association

7.894

0.048

0.267

Weak association

Cramér’s V

Cramér’s V

0.238

Weak association

18.745

0.027

0.238

Weak association

radiographers experienced barriers to CPD participation, which need to be addressed.

Financial constraints

Lack of information, % 15 24 20 10 31 100

Difficulty in getting nominated or selected to attend CPD activities, % 27 12 15 15 31 100

therefore, strive to acquire the qualifications and/or competencies required to advance professionally. Although not applicable to all radiographers, the remuneration policy in the Kenyan public sector makes provision for the acquisition of additional qualifications or specialisation to enhance work performance and facilitate advancement within the profession.[11] It, therefore, seems as if the relatively low salaries prevent radiographers from furthering their studies or subscribing to expensive scientific journals, when they are personally being held responsible for the financial implications.

Time constraints

Effect of lack of information on CPD participation at seminars and workshops 1. How regularly do you attend seminars/workshops?

Pearson’s χ2 18.745 0.027 2. How often do you read scientific journals?

Pearson’s χ2

Organisational culture, % 20 14 25 8 33 100

A large proportion of radiographers in Kenya work in health facilities in rural areas. Participants in rural areas generally experience additional infrastructure challenges, such as poorly maintained transport networks, which increase the cost of CPD participation outside their work stations.[8] This may explain why only 34% were not affected by financial constraints.

Although employers could provide financial support, managers rarely prioritise the need for CPD when allocating resources.[9] As salaries are inadequate, a good incentive or remuneration policy can act as a catalyst for the improvement and broadening of knowledge and skills.[10] This can be achieved by linking remuneration and promotion to minimum educational standards and experience for each professional level. Professionals will,

Lack of time to attend CPD activities affected 62% of the diagnostic radio­ graphers in this study. Although not investigated in our study, work pressure and family responsibilities were previously found to have an adverse effect on CPD participation.[12]

Paucity of resources

Most respondents in our study (58%) were negatively affected by a limitation of resources. Lack of access to resources contributes greatly to the challenges facing professionals. This is more obvious in rural settings, where access to resources, such as scientific journals, professional materials, the internet and study clubs, are limited.

Lack of information and communication

Competency cannot be separated from effective communication, as good personal relations and communication of information provide a stimulus that enhances participation in CPD.[13] Although the communication between SORK and its members seems to be good, a lack of information still affects the rate at which radiographers in Kenya attend seminars or workshops.

As the professional body representing radiographers in Kenya, SORK has a key role in supporting the education, lifelong learning and professional development of its members. We are, therefore, of the opinion that SORK should support members to engage in CPD by creating a platform where diagnostic radiographers can share scientific knowledge – a journal would be ideal for this purpose.[3,15] Furthermore, communication with members can be improved by providing the most current information regarding CPD activities on the website and exploring the internet as a means of providing a range of CPD opportunities.[3,15] Apart from arranging regular seminars, SORK can partner with tertiary institutions or structure the content of CPD activities to address key educational issues to improve professional practice, knowledge, skills and attitudes of radiographers.[3,15] By formulating a CPD policy employers can, additionally, be guided in developing an organisational culture conducive to participation.[8,15]

March 2017, Vol. 9, No. 1 AJHPE

19

Research Organisational culture

Although organisational culture showed no statistically significant association with CPD participation in this study, it is generally believed to contribute to non-participation of diagnostic radiographers in CPD. Professionals who work in a supportive environment maintain their motivation and job satisfaction.[14] Employers are, therefore, responsible to ensure that their workforce maintain appropriate standards by adopting a pro-CPD culture.[3] In our study, only 20% of participants expressed satisfaction with their organisational culture towards CPD (Table 1). This implies that service delivery may be adversely affected, as professionals lack opportunities to update their professional knowledge and skills. Organisational support could be achieved by advocating a culture that encourages employees to maintain and improve their professional knowledge and skills for optimal service delivery and personal advancement.[15] Support may be in the form of funding or subsidising of formal or informal CPD activities,[8] or by providing learning resources in the workplace, inclusive of current and relevant scientific publications and internet access.[3,15]

Difficulty in getting nominated or selected to attend CPD activities In our study, 42% of participants encountered difficulties in getting nominated by their employers to attend CPD activities (Fig. 1). It seems easier to obtain approval to enrol in distance learning programmes than in formal face-to-face programmes. Although not statistically significant (p=0.226), radiographers might feel deprived of formal learning opportunities owing to a lack of goodwill from their employers.

Study limitations

As all legally practising radiographers are not registered members of SORK, the sample was restricted to include SORK members only. The organisation

20

March 2017, Vol. 9, No. 1 AJHPE

currently has no power to compel radiographers to become members owing to the lack of a legislative framework.

Conclusion

Professional development in a rapidly developing and expanding profession such as medical radiography is critical for best practice. Although the majority of diagnostic radiographers in Kenya participate in CPD, a large number do not participate owing to various challenges (Fig. 1).

While organisations need to support CPD activities to optimise the benefit to the organisation, it is problematic that some still value CPD as a cost and not an investment. Although the majority of radiographers in our study considered CPD as an investment, the associated cost made it difficult for them to fully engage in CPD activities, which may have a negative impact on the standard of radiological services in Kenya.

1. Henwood S, Edie J, Flinton D, Simpson R. Continued professional development: A re-examination of the facts.

Radiography 1998;4(1):5-8. http://dx.doi.org/10.1016/s1078-8174(98)80023-0 2. Hughes P. Evaluating the impact of continual professional education. Nurse Educ Today 1990:10(6):428-436. http:// dx.doi.org/10.1016/0260-6917(90)90105-y 3. Henwood SM, Taket A. A process model in continuing professional development: Exploring diagnostic radiographers’ views. Radiography 2008;14(3):206-215. http://dx.doi.org/10.1016/j.radi.2007.03.005 4. Brink H. Fundamentals of Research Methodology for Health Care Professional Practitioners. 2nd ed. Cape Town: Juta, 2006.

5. Fox N, Hunn A, Mathers N. Sampling and Sample Size Calculation. Yorkshire: National Institute for Health Research, 2009.

6. Kothari CR. Research Methods, Research Methodology: Methods and Techniques. 2nd ed. New Delhi: New Age International, 2008.

7. Chisholm CU, Burns GR. The role of work-based and workplace learning in the development of life-long learning for engineers. Global J Engineer Educ 1999;3(3):235.

8. Henwood SM, Yielder J, Flinton D. Radiographers’ attitudes to mandatory CPD: A comparative study in the United Kingdom and New Zealand. Radiography 2004;10(4):251-258. http://dx.doi.org/10.1016/j.radi.2004.05.008 9. Brown CA. Cost effectiveness of continuing professional development in health care: A critical review of the evidence. BMJ 2002;324(7338):652-655. http://dx.doi.org/10.1136/bmj.324.7338.652 10. Palarm T, Jones K, Gilchrist M. Personal and professional development: A survey of radiographers employed in the South West Region. Radiography 2001;7(1):43-53. http://dx.doi.org/10.1053/radi.2000.0301 11. Directorate of Personnel Management. Scheme of Service for Radiographers in Kenya. Nairobi: Government Printers, 2009.

12. Schweitzer DJ, Krassa TJ. Deterrents to nurses’ participation in continuing professional development: An integrative literature review. J Contin Educ Nurs 2000;41(10):441-447. http://dx.doi.org/10.3928/00220124-20100601-05 13. Groopman J. How Doctors Think. New York: Houghton-Mifflin, 2007.

14. Broad K, Evans M. A Review of Literature on Professional Development Content and Delivery Modes for Experienced Teachers. Toronto: University of Toronto, 2006.

15. Henwood SM. Continuing professional development in diagnostic radiography: A grounded theory study. PhD thesis. London: South Bank University, 2003.

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Specialty choice among dental students in Ibadan, Nigeria K K Kanmodi,1 Dental student; A I Badru,2 MBBS, FMCA; A G Akinloye,3 BEd, MEd; W A Wegscheider,4 MD 1

Faculty of Dentistry, University of Ibadan, Ibadan, Nigeria

2

Department of Anaesthesia, Faculty of Clinical Sciences, Olabisi Onabanjo University, Sagamu, Nigeria

3

Department of Mathematics and Statistics, Faculty of Science, Osun State College of Technology, Esa Oke, Nigeria

4

Department of Dentistry and Maxillofacial Surgery, Medical University of Graz, Graz, Austria

Corresponding author: K K Kanmodi (kanmodikehinde@yahoo.com)

Background. The unequal distribution of workforce across dental specialties in Nigeria poses a significant problem in the delivery of specialists’ oral healthcare to the Nigerian population.

Objectives. To determine dental specialties preferences among dental students at the University of Ibadan, Nigeria, and to explore the factors that influence their choices.

Methods. We obtained ethical approval to conduct this study. Only the dental students who rotated through all the dental specialties were selected to participate in this questionnaire-based study. Data were analysed using SPSS version 16 (SPSS Inc., USA).

Results. The majority of dental students at the University of Ibadan preferred the oral and maxillofacial surgery (OMS) specialty above all other dental specialties, while prosthetic dentistry was least preferred. Of all the factors to take into consideration when choosing a dental specialty, personal interest was the only factor considered by nearly all respondents. Only male respondents considered prestige as an influencing factor in their choice of a specialty.

Lifestyle and job description were factors considered by a higher proportion of the male respondents (10/13) than females (5/14). The mean age of the 27 respondents who participated in this study was 22.6 years, 52% of whom were females.

Conclusion. OMS was the most preferred specialty among our respondents (n=8). Nearly all dental students chose residency training in the specialty that most appealed to them. The interest of dental students towards the least appealing dental specialties needs to be developed to solve the problem of skewed distribution of the dental workforce in Nigeria. Our findings suggest that this may be accomplished by changing dental students’ perceptions of certain specialties, building on male students’ interests in job security and private practice potential, and the female students’ interests in family-friendly specialties and increasing flexibility in dental residency programmes.

Afr J Health Professions Educ 2017;9(1):21-23. DOI:10.7196/AJHPE.2017.v9i1.670

There is a persistent shortage and an unequal distribution of workforce across the dental specialties in Nigeria.[1-3] This has been attributed to biased levels of interest by dental graduates towards all dental specialties, as a few specialties are preferred above others.[1] Oral and maxillofacial surgery (OMS) has been reported as the most preferred specialty among the majority of Nigerian dental graduates, while prosthetic dentistry (PROS) is the least preferred.[1] This is a significant problem, as some dental specialties persistently have greater manpower than other dental specialties, which hinders the adequate delivery of holistic oral healthcare to the Nigerian population.[1-3] Dental students’ and graduates’ choice of a dental specialty is determined by many factors, including potential financial income, self-employability, personal interest, job security, fear of litigation, and prestige.[4,5] The trend of specialty choice among dental students at the University of Ibadan, Nigeria has yet to be determined. The objective of this study was to determine the most preferred dental specialties among these dental students, and also to explore the factors that inform their choice. Our findings try to provide solutions to the problem of unequal preference of dental specialties.

Methods

Ethical approval to carry out this study was obtained from the Oyo State Ministry of Education, Nigeria. The study population comprised dental students in the Faculty of Dentistry, University of Ibadan. Only students who rotated through all the academic departments within the faculty were

considered eligible to participate in the study. Based on this criterion, only students in their final year were able to participate.

The study tool was a 34-item questionnaire that was self-administered to the participants after obtaining verbal informed consent. Twenty-seven final-year dental students, of a total of 35 eligible students, volunteered to participate in the study. The questionnaire had three sections: • Section A obtained information on the sociodemographic data of the participants.

• Section B obtained information on the choice of dental specialties being considered by participants for a residency programme.

• Section C obtained information on the factors that informed participants’ choice of a dental specialty.

Collected data were statistically analysed using SPSS version 16.0 (SPSS Inc., USA). The frequencies, proportions, arithmetic means, and standard deviations of variables were determined and are illustrated using a table and a chart. Tests of association between qualitative variables were done using the χ2 test; p<0.05 was considered statistically significant.

Results

The response rate was 77.1% (27/35). The mean age of the respondents was 22.6 years, and the gender distribution was fairly even, with 13 males (48%) and 14 females (52%) participating.

March 2017, Vol. 9, No. 1 AJHPE

21

Research

100

9th choice

%

90 80

8th choice

70

7th choice

60

6th choice

50

5th choice

40

4th choice

30

3rd choice

20

2nd choice

10

1st choice

0 CD

OMS

ORT

PERI

PROS CONS ORP

ORR

PD

Fig. 1. The percentage distribution of specialty choices (in ranking) among respondents. (CD = community dentistry; OMS = oral and maxillofacial surgery; ORT = orthodontics; PERI = periodontology; PROS = prosthetic dentistry; CONS = conservative dentistry; ORP = oral pathology; ORR = oral radiology; PD = paediatric dentistry.)

OMS was the specialty with the highest frequency of being the first choice (8/27 (29.6%)) of the respondents, all of whom were considering a residency training programme after graduation.

Oral pathology (ORP), OMS, and orthodontics (ORT) were the top three 1st and 2nd choice specialties. The least popular specialty choices, placed 7th, 8th, and 9th, were PROS, commu-

nity dentistry (CD), and oral radiology (ORR) (Fig. 1).

Table 1 shows the comparison between gender and factors influencing the choice of our respondents for any dental specialty. More than half of the male respondents chose a specialty based on the prestige associated with it, while none of the female respondents made a choice based on that

factor (7/13 v. 0/14, p=0.001). A higher proportion of the male respondents compared with the female respondents considered lifestyle (inclu­ ding job description) as a factor (10/13 v. 5/14, p=0.031). Further comparisons of association between gender of respondents and other influencing factors were not statistically significant (Table 1).

For men, the top influential factors were personal interest (100%), lifestyle/job description (76.9%), and job security/potential for advancement and opportunity for private practice (61.5% each).

For women, the top influential factor, as with men, was personal interest (85.7%), which was the only factor chosen by more than half of the women. The next highest influencing factors for women were easy compatibility with having a family and enough time for leisure activity (42.9% each).

All the males and females indicated that ease of entry into the residency programme and gender distribution within the specialty had no influence on their decision-making.

Prestige, others’ perception of the job, and low risk of litigation were also chosen by all female participants (100%) as having no influence on their choices.

Table 1. Comparison between gender distribution and factors influencing specialty choice among respondents Influencing factors Personal interest in the specialty Job security/advancement prospects Ease of entry into the residency programme of the specialty Lifestyle and job description Prestige Close relation with other specialties Positive influence during the posting in the specialty Opportunity to conduct research

Male (n=13) Yes, n (%) No, n (%) 13 (100) 0 (0) 8 (61.5) 5 (38.5) 0 (0) 13 (100) 10 (76.9) 3 (23.1) 7 (53.8) 6 (46.2) 5 (38.5) 8 (61.5) 7 (53.8) 6 (46.2) 5 (38.5) 8 (61.5)

Yes, n (%) 12 (85.7) 5 (35.7) 0 (0) 5 (35.7) 0 (0) 2 (14.3) 5 (35.7) 2 (14.3)

Flexibility with training Amount of patient contact Technically challenging specialty High wages Opportunity for private practice Easy compatibility with having a family Inclination of specialty before entering dental school A wide variety of caseload Influence from a mentor Enough time left for leisure activity Influence of family or relative Other people’s perception of the job Little on-call commitment Low risk of litigation Gender distribution in the specialty

7 (53.8) 5 (38.5) 2 (15.4) 6 (46.2) 8 (61.5) 4 (30.8) 1 (7.7) 3 (23.1) 6 (46.2) 4 (30.8) 1 (7.7) 1 (7.7) 2 (15.4) 3 (23.1) 0 (0)

4 (28.6) 1 (7.1) 4 (28.6) 4 (28.6) 4 (28.6) 6 (42.9) 4 (28.6) 2 (14.3) 3 (21.4) 6 (42.9) 1 (7.1) 0 (0) 1 (7.1) 0 (0) 0 (0)

*No statistics were computed because variables were constant.

22

March 2017, Vol. 9, No. 1 AJHPE

6 (46.2) 8 (61.5) 11(84.6) 7 (53.8) 5 (38.5) 9 (69.2) 12 (92.3) 10 (76.9) 7 (53.8) 9 (69.2) 12 (92.3) 12 (92.3) 11 (84.6) 10 (76.9) 13 (100)

Female (n=14) No, n (%) 2 (14.3) 9 (64.3) 14 (100) 9 (64.3) 14 (100) 12 (85.7) 9 (64.3) 12 (85.7) 10 (71.4) 13 (92.9) 10 (71.4) 10 (71.4) 10 (71.4) 8 (57.1) 10 (71.4) 12 (85.7) 11 (78.6) 8 (57.1) 13 (92.9) 14 (100) 13 (92.9) 14 (100) 14 (100)

χ2 (p-value) 0.157 0.180 * 0.031 0.001 0.152 0.343 0.152 0.182 0.050 0.410 0.345 0.085 0.516 0.163 0.557 0.173 0.516 0.957 0.290 0.496 0.057 *

Research Discussion

OMS is known to be one of the most preferred specialties among dental students and graduates.[1,4] This specialty was also the most appealing specialty among our study population. Our respondents showed little interest in specialising in PROS, CD, and ORR. This indicates a high possibility that the number of prosthetic dental specialists, community dentists and oral radiologists will remain lower than all other dental specialists in the country.

There were different factors that informed our respondentsâ&#x20AC;&#x2122; choice of a dental specialty (Table 1). We noticed that personal interest played an important role, as almost all of our respondents selected it as a major factor in their selection of a specialty. Personal interest had also been reported as a major influential factor with regard to the choice of a medical specialty among some final-year medical students at the University of Calabar, Nigeria.[6] This reveals that most students prefer the residency training programmes that are most appealing to them, but it would be helpful to know how these personal interests are formed and how they could be influenced.

Prestige, lifestyle/job description, and low risk of litigation were more commonly considered among males than females. Addressing potential misconceptions about each dental speciality during student rotations may contribute to a broader range of acceptable choices for male dental students and may change personal interests for both genders. Job security and potential for private practice were also important factors for male students. Both of these factors are strongest in specialties with fewer competitors. Pointing out that the less desirable specialties may have the highest job security and private practice potential might influence male students to consider specialities they might have otherwise overlooked. Combining a residency training programme with family life was a more common concern among female dental trainees.

The creation of residency programmes with a more flexible family-friendly structure may encourage female dental graduates to go into specialties where females tend to be under-represented or where there are shortages.

Furthermore, the gender distribution of existing specialists in a dental specialty, call duties, technicalities associated with specialist training,

perception of people about a specialty, and ease of admission into the residency programme of a specialty, among others (Table 1), did not seem to have much influence on dental studentsâ&#x20AC;&#x2122; choice of a specialty. Changes made to these factors would have less impact in attracting male or female residents to specialties.

Conclusion

We found that the majority of Ibadan dental students want to specialise in OMS, ORT, or ORP because these specialties appeal most to their personal interests. Many dental students were least interested in becoming a prosthetic dental specialist, community dentist or oral radiologist.

We conclude that there is still a strong likelihood that PROS and other less appealing specialties may remain under-staffed in the future. To prevent this, dental studentsâ&#x20AC;&#x2122; interest must be stimulated by changing their perceptions of certain specialties, building on their interests in job security and potential for private practice and, particularly for female dentists, by increasing flexibility in dental residency programmes.

Acknowledgement. The authors appreciate the assistance of Dr K E Shields, Shields Medical Writing, Greater Philadelphia area, USA, for her in-depth review of this research and manuscript. The principal investigator (KKK) also thanks Miss O M Familoni and Mr M A Owadokun for their inspiration and support.

1. Arowojolu OM, Aderinokun GA, Arotiba JY, Dosumu OO. Choice of specialty training among Nigerian graduates. Odonto-Stomatologie Tropicale 1997;77:21-24.

2. Adeniyi AA, Sofola OO, Kalliecharan RV. An appraisal of the oral health care system in Nigeria. Int Dent J 2012;62(6):292-300. http://dx.doi.org/10.1111/j.1875-595X.2012.00122.x 3. Nwhator SO, Olatosi O, Ashiwaju MO, Isiekwe GI. Emerging trends in dental specialty choice in Nigeria. Int Dent J 2013;63(2):91-96. http://dx.doi.org/10.1111/idj.12019 4. Halawany HS. Career motivations, perceptions of the future of dentistry and preferred dental specialties among Saudi dental students. Open Dent J 2014;8:129-135.

5. Arora R, Panwar NK, Dhar V. Reason for choosing paediatric dentistry as career-survey among postgraduate dental students. J Oral Health Comm Dent 2011;5(2):86-89.

6. Oku OO, Oku AO, Edentekhe T, Kalu Q, Edem BE. Specialty choices among graduating medical students in University of Calabar, Nigeria: Implications for anesthesia practice. Ain-Shams J Anesthesiol 2014;7(4):485-490. http://dx.doi.org/10.4103/1687-7934.145673

March 2017, Vol. 9, No. 1 AJHPE

23

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Pioneering small-group learning in Tanzanian emergency medicine: Investigating acceptability for physician learners A G Lim,1 MD, MS; H Geduld,2 MB ChB, DipPEC, MMed, FCEM; K Checkett,3 MD; H R Sawe,4 MD, MBA, MMed; T A Reynolds,5 MD, MS, PhD 1

Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, WA, USA

2

Education and Training, Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa

3

Section of Emergency Medicine, Department of Medicine, University of Chicago, Ill, USA

4

Emergency Medicine, Muhimbili National Hospital, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

5

Emergency and Trauma Care Programme, World Health Organization Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, Geneva, Switzerland; and Department of Emergency Medicine, University of California, San Francisco, CA, USA

Corresponding author: A G Lim (andrewglim@gmail.com)

Background. Emergency medicine (EM) is a relatively new, but growing medical specialty in sub-Saharan Africa. African EM training programmes have used small-group learning (SGL) modalities in their curricula. However, there is little knowledge of whether SGL modalities are perceived to be effective in these African EM training programmes.

Objectives. To investigate the acceptability of SGL for physicians’ training in an academic Tanzanian emergency department using a novel EM curriculum.

Methods. Using responses to a written questionnaire, we explored the perceived effectiveness of SGL compared with traditional didactic lectures among 38 emergency department physician learners in Dar es Salaam, Tanzania. Perceptions of SGL were identified from qualitative responses, and regression analyses were used to determine strength of association between quantitative outcomes.

Results. Reported benefits of SGL included team building, simulation training, enhancement of procedural skills, and the opportunity to discuss opinions on clinical management. SGL scored more favourably with regard to improving clinical practice, enjoyment of learning, and building peer-to-peer relations. Lectures scored more favourably at improving medical knowledge. Preference towards SGL over lectures for overall training increased with years of clinical experience (95% confidence interval (CI) 0.16 - 0.62, p=0.002, Spearman’s rho 0.51), and the perception that SGL reinforces learner-teacher relationships correlated with seniority within residency training (95% CI 0.14 - 0.86, p=0.007, Spearman’s rho 0.47).

Conclusion. Techniques of SGL were perceived as effective at improving clinical practice in the emergency department setting. These modalities may be more favourably accepted by more experienced physician learners – therefore, new EM teaching programmes in Africa should consider these factors when targeting educational strategies for their respective regions and learner cohorts.

Afr J Health Professions Educ 2017;9(1):24-28. DOI:10.7196/AJHPE.2017.v9i1.692

Context of emergency medicine training in sub-Saharan Africa

Emergency medicine (EM) is a relatively new, but now established and growing medical specialty in sub-Saharan Africa. According to the African Federation of Emergency Medicine (AFEM), there are specialist-level graduates of EM training programmes from South Africa (SA), Ghana, Tanzania, and Ethiopia, with several new programmes with first generations of trainees in Rwanda and Botswana, among other African nations.[1] Now that African EM has taken shape as a specialty-level discipline with academic and departmental leadership at major universities, new challenges have emerged for the continued success of the nascent field. A survey among recently graduated EM-trained specialists from the aforementioned African training programmes sought to characterise the challenges faced by the growing body of new EM practitioners.[2] The largest perceived needs were the lack of leadership development and training, including materials for training and ‘active learning’, the need for improved relationships with faculty mentors, and the need for interprofessional communication training. Failure of the EM programmes to meet these needs has led to trainees

24

March 2017, Vol. 9, No. 1 AJHPE

leaving the field, a consequence noted by the first EM training programme developed in SA.[3] A follow-up survey from the EM programme in Ghana highlighted the need for region-specific medical knowledge to enhance training curricula.[4] Many of the EM curricula used in African training programmes were based on models from prior established residency programmes in North America, Europe, and Australia. These curricula consisted of multimodal approaches to learning, with the use of small-group learning (SGL), including case-based seminars, simulation training, and procedure-based skills labs to supplement traditional didactic lectures.

While there has been evidence supporting the effectiveness and acceptance of such modalities for their countries’ respective learner populations,[5-11] there has been little or no investigation regarding the appropriateness of these modalities in the sub-Saharan African context of EM training. SGL for EM has been favourably accepted by medical students in Botswana,[12] but has not yet been explored in the postgraduate context. It cannot be assumed that western-developed educational modalities will be functionally (or culturally) appropriate for African educational norms, and investigations

Research of learner perspectives would facilitate future programme design and curricular development for EM training on the continent.

In this study, we explore the acceptability and perceived effectiveness of SGL among physician-learners at the Muhimbili University Health and Allied Sciences (MUHAS) EM training programme in Dar es Salaam, Tanzania.

These physician-learners include registrars (who have completed internship and have varying years of clinical experience, often transitioning to other specialty training or general practice by working for a limited time in the emergency department (ED)), EM residents (who have completed 1 - 3 years as registrars before joining the 3-year residency programme), and recent residency graduates <1 year out of training (now working as faculty at the ED at Muhimbili National Hospital (MNH)).

We compared the perceived effectiveness of SGL with lecture-based learning to investigate if acceptance correlates with learners’ clinical experience or other demographic factors. Our objective was to identify characteristics of the Tanzanian physicians’ experience with SGL modalities that could facilitate further development of EM residency curricula in other sub-Saharan African countries.

Emergency medicine in Tanzania

EM education was introduced in Tanzania in 2010 at MNH and has been challenged by the country’s limited basic healthcare infrastructure and access to training,[13,14] barriers exemplified in other sub-Saharan African countries.[15-17] Regardless, the demand for improved prehospital and hospitalbased EM specialty training in this country continues to grow.[18] Despite previous successes of SGL medical education in Tanzania, there have been few investigations of SGL acceptability in the region, and none for EM education. A recent study showed significant improvement to trauma resuscitation knowledge following implementation of a small-group-based resuscitation simulation course,[19] but researchers have yet to investigate the impact of SGL on other topics within the scope of EM postgraduate training.

The MUHAS EM curriculum, first introduced in 2010 with a primarily lecture-based format, was redesigned by faculty and residents in 2014 to formally incorporate SGL during educational conferences, comprising ~40% of all conference time; this included case-based small-group seminars, procedure laboratories, and resuscitation simulations. The remaining 60% of conference time consisted of traditional lectures structured around monthly subject-based modules. The new 2014 curriculum provided the first exposure to non-lecture and non-bedside teaching modalities for many of its physician-learners. A core group of 6 - 10 specialist physician instructors (from Tanzanian, the US and SA medical schools) was primarily responsible for both lecture and SGL sessions, although visiting faculty from outside Tanzania gave occasional lectures supplemental to the core curriculum.

Case-based small-group seminars (done on a weekly basis) involved groups of 4 - 6 physician-learners with a senior resident or faculty facilitator, progressing through a patient presentation with discussions regarding clinical reasoning, diagnostic testing, therapeutic management and disposition decisions. Procedure laboratories (roughly once or twice per monthly module) included technical simulation of procedural skills, including diagnostic ultrasound scans, ultrasound-guided peripheral intravenous cannulation, advanced airway management and tracheal intubation. These were typically led by faculty and involved rotating groups of 4 - 6 physician-learners.

Resuscitation simulations were also done once or twice per monthly module

and involved placing junior physician-learners as resuscitation leaders for management of emergent clinical scenarios (such as anaphylaxis, cardiac arrest, sepsis, trauma, and mass casualty triage) using low-fidelity manne­ quins, facilitator-controlled vital signs monitors, training cardioverter defibrillators, and other resources to simulate real-time, hands-on patient care.

Methods

We invited 38 physician-learners enrolled in the MNH EM training programme to participate in this study, to which all agreed. They represented all learners who had experienced the newly designed SGL curriculum at MNH’s ED at the time of data collection in March 2014 (19 residents, 14 registrars, 5 recent residency graduates). A recent graduate, one of the authors of this study, was excluded. Informed consent was obtained for each participant at the time of interview and survey administration, and subjects were not required to participate in the study. Ethical approval was granted by respective review boards of MUHAS and the University of California, San Francisco (UCSF), USA. We developed an exploratory survey using a written questionnaire to elicit both quantitative and qualitative responses through closed- and open-ended questions regarding the educational techniques used in the Muhimbili ED. Open-ended questions prompted subjects to characterise their perceptions of strengths and weaknesses of the various modalities of the SGL component of their education. To strengthen content and response process validity, the survey was designed and modified based on key informant interviews with Muhimbili ED faculty leadership and 10 of the participants. Faculty involved in AFEM curriculum development, and programme leaders of Tanzanian, SA and US EM residencies, also provided expert opinion to develop these instruments.

The 37-item written survey incorporated free response fields and Likertscale questions about physician-learners’ perceptions of SGL within the MUHAS EM curriculum. The first section of the survey comprised openended questions about the effectiveness of SGL for both the acquisition of medical knowledge and improvement of clinical practice in the ED setting (Table 1). The second section asked respondents to directly compare SGL with lecture-based learning along several educational dimensions with numerical Likert-scale responses (Table 2). These educational dimensions were adapted from a study of Indian medical students’ perceptions and acceptance of SGL v. lecture-based learning modalities, although this was originally intended for a general medical school curriculum not specific to EM education.[20] To investigate whether the acceptance of SGL was associated with learner experience, we collected data on participants’ years of clinical experience (number of years working in clinical settings following medical school), and their current level in the MUHAS EM training programme. Regression analyses were used to determine associations between learners’ clinical experience and programme level with their acceptability of SGL based on the Likert-scale survey responses.

Results

The majority of the 38 respondents were male (63%) and had 3 - 6 years of clinical experience (81%). Approximately half of respondents had some medically orientated SGL experiences prior to their EM education (47% with experience, 45% without experience, 8% no response). Respondents

March 2017, Vol. 9, No. 1 AJHPE

25

Research were distributed among varying levels of advancement within the EM training programme (Table 1).

Responses to the qualitative section of the survey were categorised into major themes, providing insight into the overall acceptability of small-group education. The most commonly reported benefits of SGL included team building/relationship building in clinical settings (n=13), the opportunity to discuss and interact with other learners (n=10), the ability to simulate clinical scenarios (n=9), the opportunity to clarify gaps in knowledge with faculty mentors (n=7), improving clinical confidence (n=6), and the enhancement of procedural skills (n=6). The summary of these findings is reviewed in Table 2.

Table 3 summarises the Likert-scale responses regarding the perceived effectiveness of SGL compared with lectures. The majority of respondents agreed that SGL was both effective at improving medical knowledge (mean (standard deviation (SD) 4.18 (0.63), where a Likert response of 1 = strongly disagree and 5 = strongly agree) and clinical practice (4.14 (0.85)). Overall, respondents felt that lectures were more effective at developing medical knowledge compared with SGL, but that the latter was comparatively more effective at improving clinical practice. SGL was preferred for enjoyment of learning and building positive peer-to-peer relations. For overall training, small groups and lectures were evenly favoured.

There was a significant and positive correlation between clinical experience and preference towards SGL for overall training compared with lectures (coeff 0.39, 95% confidence interval (CI) 0.16 - 0.62, p=0.002, R2=0.30; Spearman’s rho 0.51, p=0.003). There was also a significantly positive correlation between level of EM residency training and the perception that SGL reinforces learner-to-teacher relationships (coeff.

0.48, 95% CI 0.14 - 0.86, p=0.007, R2=0.21; Spearman’s rho 0.47, p=0.005).

Discussion

The findings of the study suggest that SGL methods implemented in a novel Tanzanian EM training curriculum had favourable learner acceptability for improving clinical practice, enhancing enjoyment of learning, and reinforcing peer relations, while lectures were favoured for improving medical knowledge.

The following themes emerged in our study with regard to the strengths and weaknesses of SGL compared with lectures: • SGL was preferred over lectures for overall training by participants with more clinical experience. The association between years of clinical experience and preference for SGL was consistent with the literature, showing that physician-learners are more satisfied with learning environments than approximate clinical practice, especially when further removed from the medical school experience.[21] • SGL reinforces learner-to-learner relationships compared with lectures.

SGL appeared to reinforce teamwork and relations among learners, especially in clinically applied settings.

• SGL reinforces learner-to-teacher relationships for participants in continued residency training. As learners progressed through the residency programme, they identified SGL as more effective at building relations with their teachers. This could be owing to the trust built over time with mentors, along with the camaraderie fostered through residency. Additionally, experienced trainees were expected to participate as teachers/leaders in both SGL and lectures, and were therefore more likely to identify with

26

March 2017, Vol. 9, No. 1 AJHPE

Table 1. Participants’ gender, clinical experience and training level (N=38) Demographics Gender Male Female Clinical experience, post-medical school (years) 3-4 5-6 7-8 Level of EM training Registrar Resident, year 1 Resident, year 2 Resident, year 3 New faculty (year 4)

n (%) 24 (63) 14 (37) 16 (42) 15 (39) 7 (18) 14 (37) 9 (24) 4 (11) 6 (16) 5 (13)

Table 2. Summary of participants’ perceptions of SGL (N=38) Effective aspects of SGL Teambuilding and peer-relationship building (n=13) Opportunities for discussion/interaction with other learners (n=10) Opportunities for practising real-life clinical scenarios (n=9) Opportunities to clarify gaps in knowledge with mentors (n=7) Improves confidence of clinical skills (n=6) Interactivity of seminar to learn physical/procedural skills (n=6) Improvement of public speaking/communication/presentation skills (n=5) Improves critical thinking and medical concepts (n=4) Ineffective aspects of SGL Small groups can be too much like mini-lectures (n=2) Small-group teaching should be divided by trainee level (n=2)

Table 3. Perceived effectiveness of lectures v. SGL (N=38) Characteristic of learning modality Improving medical knowledge Improving clinical practice Ability to organise what you’ve learned Defining/clarifying of learning objectives during lesson Developing clinical/diagnostic reasoning Developing independent critical thinking Enjoyment of learning Motivation to learn more on your own Reinforcing learner-to-learner relationship building Reinforcing learner-to-teacher relationship building Overall training

Mean (SD)* 2.20 (1.15) 4.12 (0.86) 3.79 (0.96) 2.82 (1.31) 3.24 (1.35) 3.45 (1.42) 4.15 (0.87) 3.27 (1.31) 4.12 (0.88) 3.53 (1.35) 3.45 (1.09)

*1 = lectures much more effective; 2 = lectures more effective; 3 = neutral; 4 = small groups more effective; 5 = small groups much more effective.

mentorship roles. Conversely, registrars and 1st-year residents may have felt more distanced from the small-group experience and hesitant of teacher-learner interactions, perhaps owing to nascent professional relations with their mentors. Some younger participants expressed feeling intimidated to speak out in the early years of medical school, a feeling they may have carried over to their postgraduate training.

Research There were also negative aspects to the SGL modalities that were expressed by the physician-learners. Interestingly, small groups were criticised when seminars were too ‘lecture-like’ in quality, i.e. when they failed to retain features unique to SGL. Further criticism of small groups occurred when learners were intermixed with those from other training levels. This resulted in decreased ability to form team bonds, given that the experience and knowledge among peers was discordant.

Study limitations

There were significant limitations to this study. It was a single-site study, affecting the generalisability of our findings to other African EM training programmes. Although we used a total sample of physician-learners with experience in EM-specific SGL in the only EM specialty training programme in Tanzania, the sample size was still small and thus limited in statistical significance. Our analyses would benefit further from longitudinal studies of this cohort as they progress through the curriculum.

An attempt was made to calculate effect size between the resident and regis­ trar cohorts for their overall preference of SGL v. lectures (using Cohen’s d). However, these calculations showed no significant effect size difference. Further, no significant associations were found with gender and other independent variables.

Despite attempts at ensuring the appropriateness of survey items via key informant interviews and pretesting, the instruments had not been previously validated or standardised, in part due to inability of finding existing instruments suitable for the research objectives. Therefore, specific attempts at validity testing for the quantitative portion (such as inter-item reliability) were not pursued. We solicited learner opinions of a better conduit for medical knowledge, and did not seek objective measures of medical knowledge; therefore, participants’ perceptions were undoubtedly influenced by their previous learning experiences. Furthermore, some of the participants (senior residents) also had teaching responsibilities, e.g. to lecture or facilitate small groups; this bias could not be further controlled in our analysis.

The significance of SGL being associated with improvement of clinical practice and lectures with medical knowledge deserves further exploration.

The qualitative data would suggest that clinical practice entails practical skills and the ability to perform patient care at the bedside. It is not entirely clear from the survey data if clinical practice also encompassed provider confidence, team building, communication, critical awareness, or other essential skills related to patient care. Likewise, medical knowledge may have meant basic science knowledge, clinical science knowledge, or other fundamentals of medical science; these findings require a more nuanced investigation in future research.

Conclusion

Physician-learners with more clinical experience and professional maturity tended to be more accepting of SGL as a learning modality. Residency programmes should consider these factors when deciding on which educational modalities to incorporate into their curricula. As EM educators in Africa tailor their residency programmes’ educational curricula to their regional needs, they should weigh factors such as clinical experience of their trainees and potential benefits to team building and learning enjoyment when deciding how to incorporate SGL modalities.

SGL has been a prominent feature of North American, European, and Australian EM training in recent decades. With the calls toward ‘novel’ forms of education developed in these countries, we must be careful in assuming that these learning methods will be culturally or socially appropriate for a given region’s needs in the African context.[22] If we lack an understanding of the educational context where a new training curriculum is being implemented, the curriculum could easily fail to have its desired effect. We believe that medical practitioners who are not familiar with the relevant country’s educational context must also have a strong understanding of regional educational issues, or must be working in collaboration with educational researchers well versed in the regional context.

For example, it is possible that perceptions and acceptability of SGL are different among EM residents in the USA, where the average postgraduate time period out of medical school is only 1 - 2 years. Given that the majority of Tanzanian physician-learners were in their 5th through 8th postgraduate year, this differential in experience level alone provides evidence that African EM curricula need to be designed with its unique learner populations in mind. There are also considerable differences in the nature of clinical experiences between the average Tanzanian and US physician-learners entering EM training.

Nonetheless, this research does suggest that SGL may address some of the needs identified by Bae et al.[2] in their survey of African EM specialists.

SGL may be effective in increasing relationship building between learners and mentors, promoting active learning, and building more effective leadership and communication training. However, more targeted research, and programme-specific monitoring and evaluation of the curriculum, will be needed to explore these themes further for the future development and strengthening of EM education in sub-Saharan Africa.

Acknowledgements. We would like to acknowledge Prof. V Mwafongo, MUHAS, and head of EM at MNH. We thank all participants, physicians, nurses, and other ED staff who work tirelessly on behalf of their patients, and for the advancement of EM in Tanzania.

1. African Federation of Emergency Medicine. 2016: http://www.afem.org (accessed 21 December 2016).

2. Bae C, Geduld H, Wallis LA, Smit DV, Reynolds T. Professional needs of young emergency medicine specialists in Africa: Results of a South Africa, Ethiopia, Tanzania, and Ghana survey. Afr J Emerg Med 2016; 6(2):94-99. http://dx.doi.org/10.1016/j.afjem.2016.02.005 3. Wen LS, Geduld HI, Nagurney JT, Wallis LA. Africa’s first emergency medicine training program at the University of Cape Town/Stellenbosch University: History, progress, and lessons learned. Acad Emerg Med 2011; 18(8):868871. http://dx.doi.org/10.1111/j.1553-2712.2011.01131.x 4. Martel J, Oteng R, Mould-Millman NK, et al. The development of sustainable emergency care in Ghana: Physician, nursing and prehospital care training initiatives. J Emerg Med 2014;47(4):462-468. http://dx.doi.org/ 10.1016/j.jemermed.2014.04.041 5. Maddry JK, Varney SM, Sessions D, et al. A comparison of simulation-based education versus lecture-based instruction for toxicology training in emergency medicine residents. J Med Toxicol 2014;10(4):364-368. http:// dx.doi.org/10.1007/s13181-014-0401-8 6. Li CH, Kuan WS, Mahadevan M, Daniel-Underwood L, Chiu TF, Nguyen HB (ATLAS Investigators: Asia neTwork to reguLAte Sepsis care). A multinational randomised study comparing didactic lectures with case scenario in a severe sepsis medical simulation course. Emerg Med J 2012;29(7):559-564. http://dx.doi.org/10.1136/ emermed-2011-200068 7. Wang EE, Beaumont J, Kharasch M, Vozenilek JA. Resident response to integration of simulation-based education into emergency medicine conference. Acad Emerg Med 2008;15(11):1207-1210. http://dx.doi.org/10.1111/j.15532712.2008.00208.x 8. Häske D, Beckers SK, Hofmann M, et al. The effect of paramedic training on pre-hospital trauma care (EPPTCstudy): A study protocol for a prospective semi-qualitative observational trial. BMC Med Educ 2014;14(1):32. http://dx.doi.org/10.1186/1472-6920-14-32 9. Chung SP, Cho J, Park YS, et al. Effects of script-based role play in cardiopulmonary resuscitation team training.

Emerg Med J 2011;28(8):690-694. http://dx.doi.org/10.1136/emj.2009.090605 10. Park I, Gupta A, Mandani K, Haubner L, Peckler B. Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. J Emerg Trauma Shock 2010;3(4):385-388. http://dx.doi.org/10.4103/0974-2700.70760 11. McCoy CE, Menchine M, Anderson C, Kollen R, Langdorf MI, Lotfipour S. Prospective randomized crossover study of simulation vs. didactics for teaching medical students the assessment and management of critically ill patients. J Emerg Med 2011;40(4):448-455. http://dx.doi.org/10.1016/j.jemermed.2010.02.026 12. Cox M, Chandra A. Undergraduate emergency medicine in an African medical school – experiences from Botswana. Afr J Emerg Med 2013;3(4):157-163. http://dx.doi.org/10.1016/j.afjem.2013.04.003

March 2017, Vol. 9, No. 1 AJHPE

27

Research 13. Reynolds TA, Mfinanga JA, Sawe HR, Runyon MS, Mwafongo V. Emergency care capacity in Africa: A clinical and educational initiative in Tanzania. J Public Health Policy 2012;33(Suppl 1):S126-S137. http://dx.doi. org/10.1057/jphp.2012.41 14. Hsia RY, Mbembati NA, Macfarlane S, Kruk ME. Access to emergency and surgical care in Sub-Saharan Africa: The infrastructure gap. Health Policy Plan 2012;27(3):234-244. http://dx.doi.org/10.1093/heapol/ czr023 15. Caruso N, Chandra A, Kestler A. Development of emergency medicine in Botswana. Afr J Emerg Med 2011;1(3):108-112. http://dx.doi.org/10.1016/j.afjem.2011.08.002 16. Wachira B, Martin IBK. The state of emergency care in the Republic of Kenya. Afr J Emerg Med 2011;1(4):160165. http://dx.doi.org/10.1016/j.afjem.2011.10.008 17. Wallis LA, Garach SR, Kropman A. State of emergency medicine in South Africa. Int J Emerg Med 2008;1(2):6971. http://dx.doi.org/10.1007/s12245-008-0033-3

28

March 2017, Vol. 9, No. 1 AJHPE

18. Celletti F, Reynolds TA, Wright A, Stoertz A, Dayrit M. Educating a new generation of doctors to improve the health of populations in low- and middle-income countries. PLoS Med 2011;8(10):e1001108. http://dx.doi. org/10.1371/journal.pmed.1001108 19. Bergman S, Deckelbaum D, Lett R, et al. Assessing the impact of the trauma team training program in Tanzania.

J Trauma 2008;65(4):879-883. http://dx.doi.org/10.1097/TA.0b013e318184a9fe 20. Nanda B, Manjunatha S. Indian medical students’ perspectives on problem-based learning experiences in the undergraduate curriculum: One size does not fit all. J Educ Eval Health Prof 2013;10:11. http://dx.doi. org/10.3352/jeehp.2013.10.11 21. Al-Azri H, Ratnapalan S. Problem-based learning in continuing medical education: Review of randomized controlled trials. Can Fam Phys 2014;60(2):157-165.

22. Bleakley A, Brice J, Bligh J. Thinking the post-colonial in medical education. Med Educ 2008;42(3):266-270. http://dx.doi.org/10.1111/j.1365-2923.2007.02991.x

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Self-directed learning: Status of final-year students and perceptions of selected faculty leadership in a Nigerian medical school – a mixed analysis study T E Nottidge,1 MBBS, MPhil Health ScEd, FWACS; A J N Louw,2 BEd, MEd, PhD 1

Department of Orthopaedics and Traumatology, College of Health Sciences, University of Uyo, Nigeria

2

Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Corresponding author: T E Nottidge (timnottidge@yahoo.com)

Background. Self-directed learning (SDL) is the essential mechanism of lifelong learning, which, in turn, is required for medical professionals to maintain competency because of advancing technology and constantly evolving disease care and contexts. Yet, most Nigerian medical schools do not actively promote SDL skills for medical students.

Objective. To evaluate the status of SDL behaviour among final-year students, and the perceptions of faculty leadership towards SDL in a Nigerian medical school.

Methods. A mixed research method was used, with a survey consisting of a validated Likert-based self-rating scale for SDL (SRSSDL) to assess students’ SDL behaviour. Focus group discussions with selected faculty leaders were thematically analysed to assess their perceptions of SDL. Results. The medical students reported moderate SDL behaviour, contrary to faculty, who considered their students’ SDL behaviour to be low. Faculty leadership further defined SDL as the self-motivated student demonstrating initiative in learning under the guidance of teachers, who use interactive forums for teaching. Furthermore, teachers and students should partner towards the goal of ensuring that student learning takes place. Teachers expressed concerns about SDL methods in medical schools owing to the fear that this will require medical students to teach themselves medicine without expert guidance from teachers.

Conclusion. This study suggests that final-year students have a low to moderate level of SDL behaviour. The index faculty are willing to develop teacherguided self-motivated learning for their students, rather than strict SDL. Faculty should be concerned about this behaviour and should encourage SDL in such a way that students realise its benefits to become lifelong learners. Further study of the perceptions about self-regulated learning are recommended.

Afr J Health Professions Educ 2017;9(1):29-33. DOI:10.7196/AJHPE.2017.v9i1.708

Knowles[1] defined self-directed learning (SDL) as ‘a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies and evaluating learning outcomes’. This definition is difficult to apply in an institutional setting,[2] and more so in the complex process of imparting the defined knowledge, skills and attitudes required to produce a medical doctor. In formal education, self-regulated learning (SRL) is a more feasible framework of a student’s proactive approach to learning.[3] SRL ‘describes the proactive, self-directive processes and self-beliefs, by which students become masters of their own learning’.[4] Developing skills in SRL requires the student’s ‘personal initiative, perseverance and adaptive skill that derives from advantageous motivational feelings and beliefs and metacognitive strategies’.[4] The three skills that comprise SRL are metacognition, motivation and cognition.[5] SRL expresses a student’s motivation to achieve defined academic goals utilising specific strategies, which leverage on self-efficacy beliefs.[4] Therefore, the concepts of being proactive, motivated to learn, and teacher guidance are defined components of SRL.[5] The teacher can leverage the cognitive load theory to create a conducive atmosphere for learning.

The key concept of the cognitive load theory is that the cognitive load should match the working memory of the learner. Cognitive load

occurs when several new facts (sensory information) are received without scaffolding.[6] Teacher support is needed to provide the scaffolding to help the student ‘make sense’ of the new information.[7] This teacher-directed learning has contextual overtones in the hierarchical culture of many higher education institutions, especially in Africa.

SDL in a problem-based learning (PBL) curriculum in developing countries reveals difficulties with its implementation owing to high start-up costs and the need for well-trained facilitators. This has been observed, for example, in Argentina, South-East Asia and sub-Saharan Africa (mainly in South Africa).[8-10] In the West African sub-region and specifically in Nigeria, PBL is yet to be established, although the College of Medicine, University of Ibadan, Nigeria has started implementing this programme.[11-13] Therefore, it would seem that most learning in Nigerian medical schools is not student centred or focused on developing lifelong learning skills. These skills would enhance a professional’s relevance after formal education and thus promote safe, efficient medical care. However, published work on structured medical education in Nigeria is scanty; information on types of curricula is mostly not available in public repositories.

This study attempts to answer the following question: What is the current state of SDL among the students (as trainees) and its perception among the faculty leadership (as trainers) at a Nigerian medical school? It appears to be the first structured assessment of SDL status and perception in a Nigerian medical school – its findings are transferable to other medical schools in

March 2017, Vol. 9, No. 1 AJHPE

29

Research

Methods

A sequential mixed method approach – first quantitative and then qualitative methods – was used to answer the research question of this study.[14] The quantitative data formed part of the material for discussion in the qualitative arm of the study. It therefore follows an explanatory design, where the qualitative findings help to clarify the quantitative findings. Therefore, the research followed separate phases – first the quantitative phase, followed by the qualitative phase.

A third phase of the study involved reviewing the findings from the focus group discussion with the members of the group on an individual basis, thus providing data triangulation and further enriching the data.[14] The phases of the study were as follows: • Phase I (quantitative phase): self-rating scale for SDL (SRSSDL) administered to the final-year students of the index medical school.

• Phase II (qualitative phase): focus group discussion.

• Phase III: member-checking phase; results of phases I and II discussed with members of the focus group individually. This was done to enhance the validity and trustworthiness of the data.

The SRSSDL was designed by Williamson[15] to assess SDL behaviour – the user’s level of self-directedness in learning is graded on an ordinal scale as low, medium or high. The SRSSDL is a paper questionnaire that has 60 positively worded questions, with answer options on a Likert scale.

The question domains are: (self) awareness, learning strategies, learning activities, (self) evaluation and interpersonal skills. A scoring rubric is embedded after the questions, which allows for self-scoring, although the self-scoring option was not used in this study.

Low SDL is defined in the SRSSDL as ‘guidance is definitely needed from the teacher. Any specific changes necessary for improvement must be identified and a possible complete re-structuring of the methods of learning.’ In addition, medium SDL is defined as ‘this is half-way to becoming a self-directed learner. Areas for improvement must be identified, evaluated and a strategy adopted with teacher guidance when necessary.’

High SDL ‘indicates effective self-directed learning. The goal now is to maintain progress by identifying strengths and methods for consolidation of the students’ effective self-directed learning.’

Purposive sampling was used for this study. The choice of faculty was based on the criteria that those chosen would be a head of department, considered likely to attend the event, and also the two deans involved.

Nine staff members were chosen – 3 of 3 for the basic sciences, 4 of 13 for the clinical sciences, and the 2 deans – all those selected attended or sent a representative for the focus group discussion. The selection of deans and heads of department ensured that the opinion of faculty leadership was engaged, because they play a central role in managing the teaching and learning policies of the medical school.

The questionnaires completed during phase I were collected and graded and the scores were captured on a Microsoft Excel (USA) spreadsheet for analysis. During phase II, the focus group discussion was recorded on both audio and video devices and a manual transcript of the entire audio recording was made. The feedback obtained in phase III was worked into and enriched the data analysed in phase II. Non-crossover mixed analysis was used to analyse the data. The quantitative data were captured on a Microsoft Excel spreadsheet and basic

30

March 2017, Vol. 9, No. 1 AJHPE

descriptive statistical data of the students’ ages and scores were obtained – frequencies and means, respectively. The overall mean score was used to classify the group into low, medium or high SDL behaviour, using the scoring rubric embedded in the SRSSDL. Ethical approval for this study was obtained from the ethics committee of the Faculty of Medicine and Health Sciences, Stellenbosch University (ref. no. S14/02/033). Permission to carry out the study for the purpose of college development and curriculum review was obtained from the chief executive officer of the medical school. The study was carried out in 2014.

Results

Following an explanatory design for the mixed method study, the results are presented accordingly – the quantitative findings are followed by the results of the qualitative phase of the study.

Students’ self-reported SDL behaviour

Forty of 43 final-year students participated in this study – a 93% response rate. The 3 students who did not participate were not available at the time.

Ten of the participants were female and 30 male; 34 were in the 20 - 29-year age group, while 6 were in the 30 - 39-year age group.

The mean (standard deviation) for self-directed behaviour was 212.3 (21.2) (Fig. 1), which is within the medium range of the SRSSDL scale.

Faculty’s perception of SDL

Table 1 is a summary of the results of the qualitative aspect of the focus group discussion.

Positive concepts At the start of the focus group discussion, faculty observed that the term SDL was new to them. In this first part of the discussion, faculty considered 300 250 SRSSDL score

the developing world, which are yet to develop SDL and lifelong learning in their curricula.

200 150 100 50 0 1

3

5

7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Student serial number

Fig. 1. The SRSSDL score against the student’s serial number. Most of the students’ scores are in the medium range (141 - 220), with no score in the low range (60 - 140).

Table 1. Summary of results of the qualitative aspect of the focus group discussion Positive concepts Self-motivated learning Initiative Task shifting Interactive Partnership Guided learning

Negative concepts Self-decided learning Self-teaching

Research the term SDL and discussed what it means for learning in the medical school. The categories identified were: • Self-motivated learning. The perception of faculty was of a student who is enthusiastic about learning and is determined to learn. The following comment made during the focus group meeting illustrates this: ‘… the main thing is that there is somebody who is trying to have some kind of self-motivation to learn something, hold it, improve on it without really being coerced, pushed, begged, there is self-determination to achieve something.’ (Participant 3) • Initiative. Faculty embraced the idea of students showing some initiative in reading more than the scripted material: ‘… we feel that there could be a room for initiative and also a room to explore other means even at the learning level; the students may be able to discover other things for themselves.’ (Participant 7) • Task shifting. This was seen as a positive aspect of SDL, as it transferred some responsibility for learning to the student and thus reduced the responsibility and workload of teachers. A statement of one of the partici­ pants conveys this: ‘It [SDL] will reduce our [teachers’] work.’ (Participant 8) • I nteractive. This conveyed the sense of being active, involved, talking to each other and changing each other. Interactive learning was seen to indicate learning in a group of which the teacher is a part, which was reflected by another teacher’s concept of equality, and in which the traditional hierarchy between teacher and student was de-emphasised.

Participants’ comments on this in the focus group discussion were, inter alia, the following: ‘… people in groups, making it learning, interacting … .’ (Participant 1) ‘… sit, not in a classroom, in a circular form … .’ (Participant 1) • P artnership. Faculty felt that success in the world sometimes hinged on partnerships and the same concept should be leveraged to help students feel more involved with their learning: ‘… many of these companies in the United States succeeded because they made the staff part of the company.’ (Participant 8) • Guided learning. The teachers seemed to emphasise the importance of guiding the students in the discovery of medical knowledge and to acquire relevant skills while following the prescribed curriculum: ‘It’s more of encouraging participation, that is what we are talking about, but still under, you know, a guide; still under the framework of an institution.’ (Participant 4) Negative concepts After reviewing the definition of SDL as defined by Knowles,[1] faculty members elicited some negative sentiment about it. The following negative categories were identified: • Self-directed learning. Faculty were not keen on the idea that the students decide what and how to learn, as illustrated by the following quotes: ‘… if you put a medical student to stay on his own and start learning everything by himself, set goals for himself and decide appropriate learning strategies by himself, I don’t think it’s going to be better at the

end of the day. He has a curriculum. He has a period of time he needs to learn. He needs to interact with others along the learning process.’

(Participant 3) ‘… for medical education, it will be difficult to allow the students to decide how they want to learn and what they want to learn before graduation if they all have to graduate within the same 6 or 7 years.’ (Participant 5) • Self-teaching (autodidactism). Learning by using the curriculum as a guide but without the teacher. This was expressed to question the trend of discussion that seemed to displace the teacher from the centre of the learning process: ‘Giving us the impression the student is self-directed, doesn’t need the teachers again.’ (Participant 8)

Faculty’s perception of the SRSSDL score of the students

The faculty unanimously rated the self-directedness in learning of the finalyear medical students at the university as low. They expressed surprise that the students thought of themselves as having moderate SDL behaviour.

This was a qualitative overview of the students’ learning behaviour, as they did not go into the detail of reviewing the questionnaire and its various aspects.

‘I would really want to score our student low … but if we … direct them in this self-directed learning focus, I guess from low they can get to high.’

(Participant 1)

Discussion

Radical SDL is difficult to apply in formal education and is not an appropriate pedestal for teaching and learning in medical education – this summarises the view of the faculty leadership at the index medical school and is not new in the literature.[2,16] This study adds the view of the Nigerian faculty about what SDL should entail in medical education, both in its positive and negative aspects, and the application of an SDL self-assessment tool to a group of Nigerian medical students. It also adds the results of applying the SRSSDL to a cohort of medical students, probably for the first time. Furthermore, it adds to previous research done in Africa and internationally.[10] It is clear that the faculty perception in this study is in tandem with Schmidt[16] with regard to the central role of teacher support for the selfmotivated student, but that there should be teacher guidance for those in need.

Scaffolding is an offshoot of the cognitive load theory of Sweller, in which the teacher provides support for the student in a learning task by providing a means of chunking the new information or skill, to more easily engage with working memory.[17,18] The first contact with new information is through the sensory memory, but the individul becomes aware of the data when these move to the working memory, according to the cognitive load theory.[6] Learning occurs when this information moves to the longterm memory, which has an infinite number of schematics to store and retrieve information. Cognitive overload occurs when the learner meets new information that is not organised into the schemata that allows movement to the long-term memory (usually about seven chunks).[6] SDL needs to be staged according to the capacity of the learner by reducing the amount of scaffolding, as the learner matures in self-learning.[2] Task-shifting from teacher to student would certainly make the teacher’s work easier, but the focus should rather be on how it could enhance the

March 2017, Vol. 9, No. 1 AJHPE

31

Research student’s learning. It seems that teachers do not always realise the benefits of self-discovery during the learning process and tend to want to be in charge of students’ learning. However, the faculty in this study laud an interactive model of teaching and learning and, indeed, would be comfortable for students to partner with them in this process. This is reflected in the literature on PBL, which entrenches an interactive partnership model as a means of developing SDL in medical students.[7] From the results of this study, it appears that guided learning seems to be the core of the concept of how medical students can acquire the complex knowledge and skills required of a medical doctor. This is supported by the concept of cognitive load theory. Moreover, SRL is a teaching and learning method that utilises teacher guidance, which is more appropriate for the high cognitive load in medical education than SDL. Faculty was loath to adopt a concept that seemed to do away with the need for teachers. Rather, they preferred to shift more of the work of learning to the students in an interactive model, which makes students partners in the task of learning but under the guidance of teachers. In the PBL model of applying SDL, teachers are still necessary as facilitators. However, with the objective of developing SDL in medical students at the index school, faculty’s concerns would have to be addressed.

The results of this study also demonstrate that there are some negative perceptions about the concept of SDL. Faculty members were concerned about the idea of SDL – this concept was expressed by the faculty as a facet of SDL that was not compatible with medical training, which has a defined curriculum and a fixed time of completion. Therefore, the view that a student can independently determine the subjects to study in a medical school (or any school), would be unusual to faculty in most medical schools and be precarious to the stakeholders to whom the school is socially accountable.[19] Autodidaxy is a term that has been used synonymously with SDL in the literature;[20] it speaks of self-learning or self-teaching and is considered a process in SDL. However, faculty members in this study seemed to be more concerned about autodidactism, which is self-teaching without formal education.[21] Autodidactism is therefore more in tune with the comment of the faculty, who stated that giving the student the curriculum to study without the teachers would not be a reliable way to learn medicine.

The difficulty this faculty had with regard to defining SDL is common in the literature, more so with the need to safeguard the core aspects of the curriculum.[22] Faculty was unanimous in rating the students in the low range of SDL behaviour and was rather surprised that the students’ self-assessment placed them in the moderate range. This faculty rating can be misleading, as they have not been formally orientated to the workings of SDL, and so may not have the experience to make such a judgement. Rather, the general assessment by the faculty is more likely to represent their sense of the students’ level of motivation, initiative and commitment to learning. It is also possible that the faculty have developed more SDL traits in the students than they credit themselves for.

This study may be the first where SRSSDL is being applied to medical students. Other studies have shown the application of the SDL readiness scale to medical students – somewhat different from SDL behaviour.[23] The key findings of this study centre on the perceptions of the faculty focus group, which revealed a reluctance to participate in a venture that could make students decide what and when to learn. Rather, the group

32

March 2017, Vol. 9, No. 1 AJHPE

members had expectations about what it would take to produce self-directed learners and are willing to commit to this model, which can be paraphrased as follows: The self-motivated students demonstrating initiative under the guidance of teachers who use interactive forums for teaching. In addition, the teachers and students should partner towards the goal of ensuring that student learning takes place.

The modality for practically achieving this objective was not discussed, but the underlying ethos indicates a major need for training and orientation for both faculty and students.

This model appears to be similar to SRL in the following aspects: student motivation and initiative and teacher guidance in learning, suggesting that the faculty at the medical school would prefer to operate an SRL rather than an SDL framework for teaching. Nonetheless, SDL is a concept that is probably more relevant to a postgraduate medical doctor, who can use this approach to pursue lifelong learning and thus maintain safe, relevant and efficient practice for the duration of their professional life.

In view of the aim of medical schools, i.e. to produce self-directed, lifelong learners, there is a need to determine whether SRL would achieve this goal. Furthermore, it gives teachers more control and thus would seem more attuned to a hierarchical culture. The first author’s (TEN) hierarchical cultural background may be reflected in the predominant teacher-centred culture of this medical school. Therefore, he may inadvertently prefer more teacher guidance in the teaching and learning framework in use at the index medical school. It would seem that changes in teaching and learning methods need to work with and leverage upon the background culture.

This work serves as a needs analysis with regard to the basic concepts of the faculty at this medical school to develop self-directed lifelong learners.

Faculty development forums can therefore be designed that will be relevant to their needs.

The outcomes of this study are transferable to medical schools, especially in developing economies, which are yet to engage with producing selfdirected life-long learners.

Study limitations

To interpret the students’ level of self-directedness in learning in detail would have required a faculty more conversant with the theories and practice of SDL. More depth of information on student behaviour, their challenges, and successes within the Nigerian context could have guided SDL implementation strategies.

The sampling of faculty was restricted to make the study ‘doable’, but also limited the conclusions from the study to those involved in the focus group.

A systematic sampling of all faculty members would have yielded more valid results.

This study was conducted in a medical school that was yet to implement SDL; therefore, the definition of SDL may have been more difficult to grasp fully.

Conclusion

This study suggests that the final-year students have a low to moderate level of SDL behaviour. The index faculty are willing to develop teacher-guided self-motivated learning in their students, rather than strict SDL. Faculty should be concerned about this behaviour and should encourage SDL in students, in such a way that they realise its benefits to become lifelong learners. Further study on the perceptions about SRL are recommended.

Research Author contributions. TEN conceived the study. AJNL participated in study conception. TEN collected the data and drafted the manuscript. AJNL participated in the drafting of the manuscript.

1. Knowles MS. Self-directed Learning – a Guide for Learners and Teachers. Chicago: Follett Publishing, 1975:18.

2. Grow G. Teaching learners to be self-directed. Adult Educ Q 1991;41(3):125-149. http://dx.doi.org/10.1177/­­ 0001­848191041003001 3. Loyens S, Magda J, Rikers R. Self-directed learning in problem-based learning and its relationships with selfregulated learning. Educ Psychol Rev 2008;20(4):411-427. http://dx.doi.org/10.1007/s10648-008-9082-7 4. Zimmerman BJ. Investigating self-regulation and motivation: Historical background, methodological develop­ ments, and future prospects. Am Educ Res J 2008;45(1):166. http://dx.doi.org/10.3102/0002831207312909 5. Kistner S, Rakoczy K, Otto B, Dignath-van Ewijk C, Büttner G, Klieme E. Promotion of self-regulated learning in classrooms: Investigating frequency, quality, and consequences for student performance. Metacogn Learn 2010;5(2):157-171. http://dx.doi.org/10.1007/s11409-010-9055-3 6. 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(5):371-384. http://dx.doi.org/10.3109/0142159X.2014.889290 7. Miflin BM, Campbell CB, Price DA. A conceptual framework to guide the development of self-directed, lifelong learning in problem-based medical curricula. Med Educ 2000;34(4):299-306. http://dx.doi.org/10.1046/j.13652923.2000.00564.x 8. Carrera LI, Tellez TE, D’Ottavio AE. Implementing a problem-based learning curriculum in an Argentinean medical school: Implications for developing countries. Acad Med 2003;78(8):798-801. http://dx.doi.org/­10.1097/­ 00001­888-­­200308000-00010 9. Amin Z, Hoon Eng K, Gwee M, Dow Rhoon K, Chay Hoon T. Medical education in Southeast Asia: Emerging issues, challenges and opportunities. Med Educ 2005;39(8):829-832. http://dx.doi.org/10.1111/j.1365-2929.2005.­02229.x

10. Greysen SR, Dovlo D, Olapade-Olaopa EO, Jacobs M, Sewankambo N, Mullan F. Medical education in sub-Saharan Africa: A literature review. Med Educ 2011;45(10):973-986. http://dx.doi.org/10.1111/j.1365-2923.2011.04039.x 11. Olapade-Olaopa EO, ed. The 2010 MBBS Curriculum of the College of Medicine, University of Ibadan. Ibadan: College of Medicine, 2010.

12. Gukas ID. Problem-based learning in undergraduate medical education: Can we really implement it in the West African subregion? West Afr J Med 2007;26(2):87-92.

13. Olabiyi OO, Aiyegbusi AI, Noronha CC, Okanlawon AO. Students’ view of a learning method: Opinions of first year medical and dental students in the School of Basic Medical Sciences of University of Lagos, Nigeria, about problem based learning. Nig Q J Hosp Med 2008;18(4):185-190. http://dx.doi.org/10.4314/nqjhm.v18i4.45025 14. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks: Sage, 2003:15-16.

15. Williamson SN. Development of a self-rating scale of self-directed learning. Nurse Res 2007;14(2):66-83. http:// dx.doi.org/10.7748/nr2007.01.14.2.66.c6022 16. Schmidt HG. Assumptions underlying self-directed learning may be false. Med Educ 2000;34(4):243-245. http:// doi.org/10.1046/j.1365-2923.2000.0656a.x 17. Jin J, Bridges SM. Educational technologies in problem-based learning in health sciences education: A systematic review. J Med Internet Res 2014;16(12):e251. http://dx.doi.org/10.2196/jmir.3240 18. Baker RM. Examples of scaffolding and chunking in online and blended learning environments, 2010. http:// dx.doi.org/10.2139/ssrn.1608133 19. Boelen C, Woolard R. Social accountability: The extra leap to excellence for educational institutions. Med Teach 2011;33(8):614-619. http://dx.doi.org/10.3109/0142159X.2011.590248 20. Ainoda N, Onishi H, Yasuda Y. Definitions and goals of ‘self-directed learning’ in contemporary medical education literature. Ann Acad Med Singapore 2005;34(8):515-519.

21. Wikipedia. Autodidacticism, 2014. http://en.wikipedia.org/wiki/Autodidacticism (accessed 5 January 2017).

22. Lunyk-Child OI, Crooks D, Ellis PJ, Ofosu C, O’Mara L, Rideout E. Self-directed learning: Faculty and student perceptions. J Nurs Educ 2001;40(3):116-123.

23. Premkumar K, Pahwa P, Banerjee A, Baptiste K, Bhatt H, Lim HJ. Does medical training promote or deter self-directed learning? A longitudinal mixed-methods study. Acad Med 2013;88(11):1754-1764. http://dx.doi. org/10.1097/ACM.0b013e3182a9262d

March 2017, Vol. 9, No. 1 AJHPE

33

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Self-regulated learning: A key learning effect of feedback in a problem-based learning context A G Mubuuke, BSc, MSc, MPhil, PhD Fellow; A J N Louw, PhD; S van Schalkwyk, PhD Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: A G Mubuuke (gmubuuke@gmail.com)

Background. Problem-based learning (PBL) has been adopted across many health professions training institutions. Small-group student tutorials are a major component of PBL. Facilitator feedback during a tutorial is a key activity to promote self-regulated learning.

Objective. To explore ways in which students use feedback to promote self-regulated learning in a PBL environment.

Methods. This was an exploratory qualitative study in which individual interviews and focus group discussions were conducted with health science students who had experience of the tutorial process. Data were collected through audio recording and writing of field notes. Thematic analysis was employed to generate the reported themes.

Results. Students used feedback in various ways that can lead to self-regulated learning. Their experiences were summarised into three themes, i.e. activation of prior knowledge; reflection; and formulation of a personal learning plan. From the findings, a conceptual model linking feedback and selfregulated learning in a PBL context was developed.

Conclusion. In this study, we propose a conceptual model illustrating how feedback is a major activity in the critical pathway that leads to self-regulated learning.

Afr J Health Professions Educ 2017;9(1):34-38. DOI:10.7196/AJHPE.2017.v9i1.715

Following its initial conception at McMaster Medical School,[1] problem-based learning (PBL) has been adopted by many health professions institutions.[2] PBL is preferred, because it fosters student-centred learning compared with traditional didactic teacher-centred lectures.[3] It allows students to construct new knowledge based on previous knowledge through regulation of their own learning. The focus of PBL is the tutorial process, which allows students to take control of their own learning.[3] During this tutorial process, a small group of students meet and discuss a given learning task, which can take on many forms, such as a written problem, clinical case scenario, or clinical vignette. This task stimulates the students’ discussion, thereby acting as a trigger for learning.

During the tutorial process, the lecturer facilitates the students’ discussion to ensure that it is aligned to the institutional learning objectives,[4] ensuring that students understand the concepts of the problem and formulating appropriate learning objectives, which subsequently guide their self-directed independent study. In PBL, therefore, the role of the lecturer (who in the tutorial is called a tutor) is to guide students and promote sharing, interaction and exchange of ideas towards constructing new knowledge.[4] Learning in a PBL tutorial group is aimed at enhancing activation of prior knowledge, elaboration of such knowledge, and discovering new knowledge to build on prior knowledge through students’ own self-directed and selfregulated learning processes.[3,4] Self-regulated learning has been described as learning where students use various mechanisms to take control of their own learning processes.[5] They are proactive, and they direct and control their own learning.

Zimmerman[5] reports that students’ achievements cannot only be attri­ buted to abilities, but that skills to participate in self-regulated learning also contribute. Zimmerman and Schunk[6] as well as Zimmerman[5] further report that in self-regulated learning, students should be active participants in learn-

34

March 2017, Vol. 9, No. 1 AJHPE

ing rather than passive recipients of knowledge, tenets that are evident within a PBL tutorial. Other studies have shown that students’ interest in a subject influences their self-regulation.[7,8] For example, students who are highly interest­ed in a subject are likely to use efficient self-regulatory strategies to learn independently, even in the absence of tutors.

During the process of guiding students in a PBL tutorial, the tutor delivers feedback, identifying strengths, as well as learning gaps that need to be addressed. Feedback has been described as the exchange of information by human beings in a problem-solving situation.[9] In the context of this study, it can be viewed as the exchange of information between tutors and students regarding performance during PBL tutorials.

Feedback acknowledges students’ progress in relation to achieving the intended learning objectives.[9] By providing an opportunity for students to reflect and act upon the received feedback, tutors indirectly facilitate not only students’ learning, but also their self-regulated learning skills.[9] Therefore, effective feedback has been defined as being concise, clear, specific and timely and identifies learning strengths and gaps.[9] Butler and Winne[10] link the concepts of feedback and self-regulation. They described self-regulated learners as those who possess skills of setting goals to acquire knowledge, and discuss strategies to address these goals while monitoring, evaluating and reflecting upon the process, sometimes re-shaping their initial goals to achieve their objectives. During this entire process of self-regulation, Butler and Winne[10] conclude that ‘feedback is an inherent catalyst’.

Pintrich[11] further reports that self-regulation is an ‘active constructive process whereby learners set goals for their learning and then attempt to monitor, regulate, and control their cognition, motivation, and behavior, guided by their goals’. The concepts of self-regulation reported by Butler and Winne[10] and Pintrich[11] are evident in a typical PBL tutorial process, where feedback is an integral part. Hattie and Timperley[12] concur that self-

Research regulation is vital to effective learning, and that feedback offers an opportunity to students to practise self-regulated learning.

Self-regulated learning theory was advanced by Pintrich.[11] It comprises four phases of self-regulation, including: (i) forethought, planning and activation; (ii) monitoring; (iii) control; and (iv) reaction and reflection. These phases of self-regulated learning are also evident in a PBL tutorial. The theory emphasises that with self-regulation, learners: (i) should be active participants in the learning process; (ii) have the potential to control key learning activities; (iii) have goals against which to assess progress; and (iv) mediate personal factors and performance outcomes.

From the literature, one can identify that self-regulated learning can be achieved within a PBL context, as it is a student-centred instructional approach. One can also identify that feedback of performance with regard to learning tasks has the potential of promoting self-regulated learning. However, a key question arises, i.e. how do students utilise feedback received within the PBL environment to promote self-regulated learning? This question formed the basis of this study.

Methods

Study setting

The study was conducted at the College of Health Sciences, Makerere University, Kampala, Uganda.

The institution trains undergraduate students across various health disciplines using a PBL approach. Small-group tutorials of ~8 - 10 students are conducted twice a week, facilitated by a tutor, who also delivers feedback to students.

Research design

This was an exploratory qualitative study. This kind of design allowed an in-depth understanding of a subject from the perspective of participants.[13] Adopting this study design was aimed at obtaining an in-depth insightful understanding of how students used feedback to engage in self-regulated learning in a PBL tutorial context.

Study participants

Purposive sampling was used to select the student participants. These included 3rd-year undergraduate health science students across five disciplines: medicine, dentistry, radiography, pharmacy and nursing. Third-year students were chosen because they attend tutorials within their specific professional disciplines and were not integrated. In total, 25 individual interviews and five focus group discussions were conducted. Each focus group consisted of 6 - 8 students.

Data collection and management

Data were collected during in-depth individual interviews and focus group discussions. The interview sessions and focus group discussions were conducted in English. Questions used to guide the interviews and focus group discussions were open-ended and semi-structured, which allowed participants to freely express their experiences without being directed. The development of these questions was informed by the literature and generally explored ways in which students used feedback to engage in self-regulated learning. The questions for both the individual interviews and focus group discussions were first piloted to assess clarity. Using two methods of collecting data was for purposes of triangulation. Responses from the participants were audio recorded and later transcribed. The transcribed data were put into electronic format and stored on one computer secured by a password. These data were accessible only to the researchers.

Data analysis

Thematic analysis was used. Analysis was carried out manually by the researchers. Raw data were read and through a series of iterative and inductive open and axial coding, codes were developed. This involved reading through the participants’ responses, identifying common meanings and coding them.

Specific codes were developed, related to each other to generate broader categories of similar responses. These were also related to each other and to the raw data, subsequently resulting in major themes that were used to report findings.

Quality assurance

Participants were invited to validate emerging themes. Furthermore, researcher bias was minimised by having more than one researcher; they avoided all preconceived ideas or experiences of the subject under investigation, thus practising reflexivity and bracketing throughout the research process. The researchers engaged in the research process with an open mind and did not impose their own views and ideas on the participants. Using more than one data collection method also added rigour to this study, and thus improved quality of the data collected.

Ethical considerations

Participants provided written informed consent, and their anonymity and confidentiality were ensured. Permission to conduct the study was granted by the Health Research Ethics Committee, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa, and the Research and Ethics Committee, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda (ref. no. S15/04/071).

Results

The purpose of this study was to explore how students used tutor feedback received in a PBL tutorial to engage in self-regulated learning practices.

Various ways in which students used feedback to become self-regulated learners were identified. These have been grouped into three themes, presented below:

Theme 1: Activation of prior knowledge

Students used feedback to activate their prior knowledge, recalling what they knew about the learning task from accumulated learning experiences. The following were typical responses: ‘I always used feedback from my tutor to try and link up the concepts that I already knew from my high school to solve the learning tasks given to me … .’ (Medicine student) ‘The PBL problems sometimes looked very knew to me and at first, I could not figure out how to tackle them. However, I realised that the tutor feedback reminded me of certain concepts I had learnt from previous problems which I recalled. This helped a lot … to drive my understanding.’

(Radiography student) ‘Many PBL cases especially in first year were actually related to my high school concepts … even second year cases were related to first year cases.

I therefore had to recall most of that data … the tutor feedback was vital in this recall process because the tutor would give us trigger responses and questions which enabled us to recall the already learnt information … .’

(Nursing student) ‘The tutor feedback assisted me to recall many concepts I had already learnt. I had forgotten them and yet they were applicable to the new PBL

March 2017, Vol. 9, No. 1 AJHPE

35

Research case … this is why tutors should attend all our tutorials … their feedback helps us a lot.’ (Pharmacy student) From the responses above, one can observe that tutor feedback in the form of triggers, challenging observations, comments and questions in a PBL tutorial enabled students to recall information acquired from previous experiences and apply it to solve a current learning task.

Theme 2: Reflection

Students used feedback to reflect on their own performance. From numerous responses, this reflection seemed to centre around self-appraisal regarding competency, using feedback received, discovering strengths and identifying learning gaps that still needed to be addressed. The following responses were a common thread: ‘The feedback I received from my tutors often helped to critique my own contribution to the tutorial discussion because from this feedback, I would discover where I did best and where I needed to improve. Without this feedback … I would not consider some aspects probably.’ (Dentistry student) ‘I think the beauty with our PBL tutorial feedback is that it engages one to appraise oneself regarding mastery of the concepts in the tutorial problem. Personally, I used to find it hard to internally evaluate myself objectively. With tutor feedback, it is easy for me to use those comments, look at what he said I did well and what I did not do well … and this pushes me to work even harder to cover my gaps.’ (Medicine student) ‘The biggest strength of this feedback process in the tutorial is that it teaches you how to self-evaluate your own work. The comments generated by the tutor are so important in guiding us on where we need to maintain and also improve. It teaches us to critically think about our work and gauge our own performance.’ (Radiography student) ‘The tutors have always been talking about reflection about our work, but they had failed to teach us how to reflect effectively. The feedback I get from my tutor has actually done the trick. I use the comments from my tutor to evaluate myself and reflect upon my own performance … this helps me a lot … all tutors should give us good feedback. It is better than preparing a power point lecture teaching me how to reflect.’ (Pharmacy student) The responses set out above illustrate how tutor feedback enhanced reflective practice. It seemed that feedback played a crucial role in directing the students to practise reflection and self-appraisal regarding their performance, identifying both strengths and areas that needed improve­ment.

Theme 3: Formulation of a personal learning plan

Students used feedback to design their own learning plans. The identified learning gaps became their learning objectives. From the responses obtained, the feedback appeared to assist students to clearly identify and formulate learning objectives that would guide their self-study, organise and plan for adequate time frames to cover objectives, identify key knowledge sources to obtain information that would address the learning objectives, and then apply new knowledge gained to fully solve the learning task. The following responses were typical:

36

March 2017, Vol. 9, No. 1 AJHPE

‘The feedback we received in our groups was very instrumental in helping us form our learning objectives. It is these objectives that guided our selfdirected learning.’ (Nursing student) ‘To me, the tutor feedback assisted me to identify my knowledge gaps and this gave me an opportunity to plan on how to discover that knowledge and where to get it from. Most likely without such feedback, my learning would not have been directed effectively.’ (Dentistry student) ‘I think the overall advantage I see with tutor feedback is that it enables students to identify from tutor comments what they have done well and what they need to improve upon. Areas that need improvement then become our learning objectives that direct our self-study. With such objectives formulated, I can then draw up my own learning time frames and identify sources of information to cover the objectives.’ (Medicine student)

Discussion

The purpose of this study was to explore ways in which students used tutor feedback received within a PBL tutorial to engage in self-regulated learning.

There were no major variations in responses received from students across various health science disciplines. The reason for this observation is not clear-cut. A possible explanation could be that the students who participated were drawn from the same PBL environment, where they share the tutors and learning resources.

Tutor feedback prompted students to utilise key activities identified in this study to engage in self-regulated learning. These included: activation of prior knowledge, reflective practice, and formulation of personal learning plans.

These can be linked to self-regulated learning theory, which emphasises activation of what is already known, as well as reflection.[11] Therefore, PBL tutors need to be aware that feedback is vital in engaging students into selfregulated learning processes. Such feedback should therefore be packaged and delivered efficiently.

Activation of prior knowledge

Students in this study used feedback received from tutors to activate prior knowledge. This finding resonates well with what is postulated in self-regulated learning theory, i.e. activating prior knowledge activates self-regulated learning processes.[6,7] Therefore, feedback could be one way of achieving this. Activation of student prior knowledge to solve PBL learning tasks has also been previously emphasised in the PBL literature.[4] Gijbels et al.[2] reported that students possess much knowledge of previous learning experiences, and new learning tasks should build on what students already know.

Effective PBL tutors should be able to invoke what students already know so that newly acquired knowledge builds on what is already known.

Good feedback in a PBL tutorial is one way of stimulating students to recall already acquired knowledge to solve new learning tasks.[3] Our findings resonate well with these previous findings. It can be discerned from our study that tutor feedback helped students to recall concepts already learnt to solve new PBL learning tasks. The feedback probably also assisted students to place their knowledge in sequence, relating new information to what is already known. Therefore, good feedback delivery practice is one way through which tutors can assist students to recall already learnt knowledge, subsequently engaging them in self-regulated learning. This study did not specifically focus on exploring attributes of good feedback. However, one

Research could notice that students perceived some feedback as beneficial, which implicitly reflected the attributes of good feedback reported in the literature.

For example, students expressed that specific, clear and unambiguous feedback was significant in their learning. Specificity and clarity of feedback have been reported as some of the good feedback attributes.[12]

PBL task

Discussion of task

Knowledge application

Self-regulated learning

Self-directed study/learning

Formulation of learning plan

Effective feedback

Reflection

Feedback also assisted students to reflect about performance. This finding is in agreement with what is reported in self-regulated learning theory, i.e. active reflection about performance promotes self-regulated learning.[7,8] The importance of training reflective health professionals has been previously emphasised.[14] This reflective practice is vital, as it helps health professionals to independently appraise their own performance, identifying strengths and areas that need improvement.[14] Although the literature emphasises the importance of training students how to engage in reflective practice,[15] there is a dearth of reported literature on how to teach reflection.

Findings from this study probably contribute to this gap. We identified that good tutor feedback in a PBL context could probably be one way through which students can be trained how to reflect. Such feedback should be specific, timely and clear. Feedback comments from tutors most likely trigger students to think about the task and their own performance of the task, and identify what they did well and where they need to improve.

Students therefore engage in a form of self-evaluation, using the feedback received, which enhances their self-regulated learning.

Formulation of a personal learning plan

Feedback enabled students to form their personal learning plans. This finding relates well to self-regulated learning theory, which postulates that self-regulated learners always form personal learning goals against which to assess progress.[11] Clearly forming a learning plan to address a learning task is a vital step in a PBL tutorial. A learning plan may include aspects such as forming learning objectives (which emanate from initially identified learning gaps) and mapping out key sources of information to address those objectives and subsequently solving the learning task. It is sometimes a challenge for students to suggest a clear learning plan from the tutorial;[1] therefore, the tutor has a role to play by guiding students to create a clear learning plan.

While it is standard practice in PBL for students to derive their own learning objectives, they may not be able to satisfactorily achieve this, even when the tutor is present to guide them. Sometimes the tutor feedback may be inefficient in guiding students to derive good learning objectives. The key message in this study is that effective feedback from the PBL tutor regarding studentsâ&#x20AC;&#x2122; strengths and learning gaps with regard to the presented task and relating this feedback to the intended learning outcomes make this process easier. Therefore, while tutors may deliver feedback, it may not assist students to form their learning objectives. This feedback must follow good feedback principles to achieve this. If tutor feedback is inefficient, even though the tutor is present, students might struggle. Feedback that is specific, focused and clear assists students to only focus on those key areas pertinent to the PBL task and not digress into other irrelevant issues. Often, students without tutor guidance formulate learning objectives that are skewed away from the intended institutional learning outcomes.[4]

Reflection

Fig. 1. A conceptual model relating feedback and self-regulated learning in a PBL tutorial.

Feedback and self-regulated learning: A conceptual model

From the preceding discussion, one can discern that tutor feedback in a PBL tutorial can probably assist students to take charge of their own learning through activation of prior knowledge, engagement in reflective practice, and formulation of personal learning plans to address any gaps that may exist. All these cognitive activities, driven by feedback, are part of selfregulated learning. Based on these findings, a conceptual model has been developed linking feedback and self-regulated learning within a PBL tutorial environment (Fig. 1). The model illustrates that good feedback is vital in the critical pathway towards training self-regulated learners.

The model postulates that self-regulated learning is central in a PBL tutorial setting, where students direct and plan their own learning. Various activities contribute to self-regulated learning. At first, there is an initial learning task, which then triggers active student discussion, activating prior knowledge to solve the task. Vital to this process is the feedback students receive from the PBL tutor regarding performance of the task. This feedback, which must follow good feedback principles, such as being timely, unambiguous and specific,[12] then engages students in active reflection about the task and how they have solved it. It is therefore the feedback in the tutorial that initiates this process of reflection. During this reflective process, students identify learning gaps and formulate a learning plan to cover those gaps. The plan might include raising learning objectives, identifying knowledge sources, and putting in place time frames to cover the objectives before a new task is introduced.

With a learning plan, students then engage in self-directed study, where they use sources of knowledge already identified and tutor feedback to address the learning objectives of the task. Subsequently, students apply this newly acquired knowledge from self-directed study to not only cover the learning gaps of the initial PBL task, but also to solve future learning tasks. From the model one can observe that self-regulated learning within a PBL context involves many activities, of which tutor feedback is very vital. Each of these activities, evident within a PBL tutorial, contributes to promote self-regulated learning processes in students.

March 2017, Vol. 9, No. 1 AJHPE

37

Research Findings from this study are generally in agreement with the literature, which shows that feedback can promote self-regulated learning. What this study adds to the literature is how feedback promotes self-regulated learning in a PBL context. It has been observed from the study that tutor feedback promotes activation of prior knowledge, gives students an opportunity to engage in reflection, and formulate learning objectives that subsequently guide their selfdirected learning. This ultimately leads to self-regulated learning.

The study involved small numbers of student participants from one institution. This and the non-probability sampling technique are major study limitations. Although the focus was on students from one institution only, it is envisaged that involving many more students and other stakeholders, such as PBL tutors and feedback experts from more than one institution, would probably have added richness to the findings. The conceptual model developed from this study also presents new thinking and gives direction for future research in health professions education. This model was developed from one institution and therefore calls for its testing and validation in other settings, which is likely to give more insight on the issues raised within this framework.

Conclusion

This study demonstrated that tutor feedback assisted students to activate prior knowledge, engage in active reflection, and formulate their own learning plans – processes in self-regulated learning. Therefore, PBL tutors

38

March 2017, Vol. 9, No. 1 AJHPE

should be aware that self-regulated learning, which PBL aims to promote, is a key learning effect of effective feedback.

1. Schwartz P, Mennin S, Webb G. Problem-based Learning: Case Studies, Experience and Practice. London: Kogan Page, 2001.

2. Gijbels D, Dochy F, van den Bossche P, Segers M. Effects of problem-based learning: A meta analysis from the angle of assessment. Rev Educ Res 2005;71(1):27-61. http://dx.doi.org/10.3102/00346543075001027 3. Gukas ID. Problem-based learning in undergraduate medical education: Can we really implement it in the West African subregion? West Afr J Med 2007;26(2):87-92.

4. Savery JR. Overview of problem-based learning: Definitions and distinctions. Interdisc J Problem Based Learn 2006;1(1):9-20. http://dx.doi.org/10.7771/1541-5015.1002 5. Zimmerman BJ. Theories of self-regulated learning and academic achievement: An overview and analysis. In: Zimmerman BJ, Schunk DH, eds. Self-regulated Learning and Academic Achievement: Theoretical Perspectives.

2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates, 2001:1-38.

6. Zimmerman BJ, Schunk DH. Self-regulated Learning and Academic Achievement: Theoretical Perspectives. 2nd ed.

Mahwah, NJ: Lawrence Erlbaum Associates, 2001.

7. Pintrich PR, Zusho A. The development of academic self-regulation: The role of cognitive and motivational factors. In: Wigfield A, Eccles JS, eds. Development of Achievement Motivation. San Diego, CA: Academic, 2002:249-284.

8. Yang M, Carless D. The feedback triangle and the enhancement of dialogic feedback processes. Teach Higher Educ 2013;18(3):285-297.

9. Orsmond P, Maw SJ, Park JR, Gomez S, Crook AC. Moving feedback forward: Theory to practice. Assess Eval Higher Educ 2013;38(2):240-252. http://dx.doi.org/10.1080/02602938.2011.625472 10. Butler DL, Winne PH. Feedback and self-regulated learning: A theoretical synthesis. Rev Educ Res 1995;65(3):245-281. http://dx.doi.org/10.3102/00346543065003245 11. Pintrich PR. The role of goal orientation in self-regulated learning. In: Boekaerts M, Pintrich PR, Zeidner M, eds.

Handbook of Self-regulation. San Diego, CA: Academic, 2000:451-502.

12. Hattie J, Timperley H. The power of feedback. Rev Educ Res 2007;77(1):81-112. http://dx.doi.org/­ 10.3102/003465430298487 13. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101. http://dx.doi. org/10.1191/1478088706qp063oa 14. Mubuuke AG, Kiguli-Malwadde E, Kiguli S, Businge F. A student portfolio; the golden key to reflective, experiential and evidence-based learning. J Med Imaging Radiat Sci 2010;41(2):72-78. http://dx.doi.org/10.1016/j. jmir.2010.03.001 15. Hughes M, Heycox K. Promoting reflective practice with older people: Learning and teaching strategies. Austr Social Work 2005;58(4):344-356. http://dx.doi.org/10.1111/j.1447-0748.2005.00231.x

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology L Jacobs-Nzuzi Khuabi, BSc (Occ Ther), MPH (Health Economics); J Bester, BOT, BSc Hons (Health Sciences), MPhil (Higher Education), Postgrad Dipl (Program Monitoring and Evaluation); K Gatley-Dewing, BOT; S Holmes, BOT; C Jacobs, BOT; B Sadler, BOT; I van der Walt, BOT Division of Occupational Therapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: L Jacobs-Nzuzi Khuabi (leeann@sun.ac.za)

Background. The South African (SA) health system is characterised by limited resources, high bed turnover rates and a high therapist-to-patient ratio.

Patients with neurological dysfunction form a large majority of the caseload of occupational therapists. Feedback from stakeholders alluded to some discrepancies between the content taught in the Stellenbosch University undergraduate curriculum and what is expected within the clinical setting. This raises questions regarding the relevance and applicability of what undergraduate occupational therapists are taught, given the nature and demands of the SA public health system.

Objective. To explore the perspectives of final-year occupational therapy students with regard to the core competencies required for optimal preparation of students for practice in the field of neurology.

Methods. This explorative study used three focus groups to obtain the perspectives of 18 final-year students who had experienced clinical placements in neurology. Information from the focus groups was transcribed and analysed thematically to determine the findings.

Results. Analysis of the data revealed four themes, i.e. core knowledge and skills; attitude; resource and time constraints in clinical areas; and factors influencing optimal learning experiences.

Conclusion. The curriculum should prepare students to be well equipped for the current climate of the profession. While the current neurology curriculum may be viewed as having some positive features, there are some aspects that need to be updated and revised. Key considerations to optimise learning include a more regular interface between clinical areas and the university, scheduling of teaching blocks, and applying relevant teaching methods.

Afr J Health Professions Educ 2017;9(1):39-43. DOI:10.7196/AJHPE.2017.v9i1.722

Patients with neurological dysfunction form a large proportion of the patient population treated in the healthcare system.[1] Dysfunction has a large impact on patients’ functioning, which necessitates treatment from an occupational therapist and, therefore, forms a substantial portion of occupational therapists’ workload. Patients’ limited access to therapy and the high patient turnover mean that occupational therapists need adequate knowledge, experience and problem-solving skills to enable independent functioning of their patients in the shortest possible time.[2] Informal feedback from stakeholders (occupational therapy clinicians, students, and clinical educators) alluded to some discrepancies between the content taught in the Stellenbosch University (SU) undergraduate curriculum and what is expected within the clinical setting. This raises questions regarding the relevance and applicability of what undergraduate occupational therapists are taught, given the nature and demands of the South African (SA) public health system. It is important that training programmes align with the health needs and available resources, in this case specifically within the SA context. According to Freeme,[3] the ideal curriculum should consider the development of knowledge and skills from the latest research, the available resources on the clinical platform, and input from relevant stakeholders. It is essential that the restricted time for the teaching of neurology should be dedicated to the most relevant knowledge and skills needed in practice.[3] McCluskey[4] and Unger and Hanekom[5] conducted studies in the domain of curriculum development in the health sciences. McCluskey[4] identified the following categories for development of the neurology curriculum:

foundation studies; assessment; treatment; and the building of confidence.

To encourage confidence in practice, it was suggested that students gain more practical experience in the classroom and clinical setting, and a more sound knowledge of contemporary scientific literature in the field of neurology. The study by Unger and Hanekom[5] identified three essential criteria deemed appropriate for determining the core content of a revised undergraduate curriculum. Content should be included in the curriculum if it: (i) is relevant to the SA context; (ii) ensures safe and effective practice by first-line practitioners; and (iii) is evidence based.

Studies by Chiang et al.[6] and Naidoo et al.[7] provide insight on students’ perspectives with regard to their readiness for clinical practice. The findings of the first-mentioned study indicated that a negative clinical experience may cause students to feel overwhelmed. This is often linked to inadequate guidance from clinical supervisors (lack of clear expectations and communication, understanding of students’ learning needs and limited feedback) and inadequate preclinical preparation (limited time to practise techniques and to refresh theoretical knowledge).[6] The latter study found that the students’ level of confidence to practise was directly related to their degree of enjoyment and their fieldwork experience. There were, however, some concerns with regard to the curriculum content, teaching methods, and relationships with the lecturer and clinical supervisors.[7] An important consideration is to include all stakeholders (occupational therapy clinicians, students and educators, client groups, employers, and professional boards) when developing a new curriculum.[8] Stakeholders

March 2017, Vol. 9, No. 1 AJHPE

39

Research could aid in developing the content, teaching methods, evaluation requirements, and the delivery of the curriculum.

The purpose of this article is to investigate the students’ views on the core competencies needed by final-year occupational therapy students in the field of neurology. Competence is defined as a multidimensional and dynamic concept that includes more than knowledge – the understanding of knowledge, interpersonal skills, clinical skills, clinical judgement, problemsolving and technical skills.[9] The students’ views as stakeholders form part of a larger study conducted at SU, which furthermore investigates the views of clinicians and academics to inform the revision of the neurology curriculum.

Methods

An explorative approach within a qualitative paradigm was used to explore the perspectives of 4th-year undergraduate occupational therapy students regarding the core competencies needed to work in the field of neurology.

Total population sampling was used.

Participants included 18 final-year occupational therapy undergraduate students at SU who had placements in neurology in their final clinical block in the 3rd year or first clinical block in the 4th year. The study population was representative of participants who had exposure to neurology within primary, secondary and tertiary levels of healthcare, and learners with special needs from the Department of Education. Table 1 displays each participant’s clinical placement according to the sector, and the diagnosis that they were exposed to.

Data were gathered through the use of three focus groups discussions (5 - 7 participants per group), lasting ~1 hour each. The focus groups were conducted by the researchers, using a predetermined question guide. The questions focused on the students’ perspectives of the core knowledge, skills, and attitude required for practising neurology. It also explored the resource constraints they experienced in the clinical placements and aspects they viewed as important in the revision of the neurology curriculum.

Burnard’s[10] 14-step method of data analysis for semi-structured interviews was used. The audio-recordings from the focus groups were transcribed verbatim. Inductive coding was done using the Qualitative Data Analysis (QDA) Miner 4 analysis program (Provalis Research, Canada).[11] Lincoln and Guba’s[12] model of trustworthiness for qualitative research was used to ensure rigour. Credibility was ensured by acknowledging and analysing the researchers own preconceptions of the topic and their experiences of the neurology curriculum for objectivity. The researchers also used investigator triangulation, member checking and peer checking.

Transferability was obtained by thick description of procedures for data collection and analysis. For dependability, the data were coded twice, checking that codes correlated. Confirmability was ensured through investigator triangulation and reflexivity.

Ethical clearance was obtained from the SU Health Research Ethics Committee (ref. no. N14/09/118) and the SU Institutional Research and Planning Committee, which oversees ethics of research involving the student population. Permission was also obtained from the Undergraduate Programme Committee of the Division of Occupational Therapy, SU. Ethical principles were upheld by giving the participants a choice to participate and respecting their opinions during the focus group discussions.

Confidentiality was ensured by allocating participants pseudonyms, and all transcribed data were kept on password-protected programs to which only the researchers have access.

40

March 2017, Vol. 9, No. 1 AJHPE

Table 1. Participants’ clinical placements according to sector and diagnosis to which they were exposed Participant 1 2 3 4

5 6 7 8 9

Sector Health: secondary level of care Health: primary level of care Education: special needs school Health: tertiary level of care Health: secondary level of care Health: secondary level of care Education: special needs school Health: primary level of care

14

Health: primary level of care Health: secondary level of care Health: Secondary level of care Health: primary level of care Health: secondary level of care Education: special needs school Health: secondary level of care Health: tertiary level of care

15 16 17

Health: primary level of care Health: primary level of care Health: tertiary level of care

18

Education: special needs school Health: tertiary level of care

10 11 12

13

List of diagnoses exposed to CVA, spinal cord injuries Spinal cord injuries, amputations, TB spine CP, neuro-psych Paediatric: CP, neuro-psych, TB spine CVA, spinal cord injuries CVA, spinal cord injuries, TB meningitis CP Spinal cord injuries, amputations, TB spine CVA, TB spine TB meningitis CVA CVA, TB spine CVA, CP CP CVA Paediatric: CP, neuro-psych, TB spine CVA CVA Paediatric: CP, neuro-psych, TB spine CP CVA, TBI

CVA = cerebrovascular accident; CP = cerebral palsy; TB = tuberculosis; TBI = traumatic brain injury; neuro-psych = neurology psychology.

Results

Analysis of the data revealed four themes that participants felt should be considered for inclusion when revising the curriculum (Fig. 1). These themes are: core knowledge and skills; attitude; resource and time constraints in clinical areas; and factors influencing optimal learning experiences.

Theme 1: Core knowledge and skills

This theme encompasses core generic knowledge about pathology, anatomy and practice models. It furthermore includes core knowledge and skills pertaining to occupational therapy-specific neurological assessment, treatment and knowledge of own, and other professions’ scope and role within an interdisciplinary team.

Research ‘ We need to be taught how to do something in an hour, functionally and especially for the high turnover.’

Pathology Foundational knowledge

Anatomy

Theme 2: Attitude

Models and frames of reference

Test mechanics Theme 1: Core knowledge and skills

Assessment Selection of appropriate assessments Patient and family education Activity analysis Treatment Activities of daily living Functional assistive devices

Team members Client centredness Theme 2: Attitude

Self-directed learning Confidence

Theme 3: Resource and time constraints in clinical areas

Availability of resources Theme 3: Resource and time constraints in clinical areas Limited time for intervention Up-to-date information and evidence-based practice Theme 4: Factors influencing optimal learning experiences

Practical exposure Closer interface between academics and the clinical areas

Fig. 1. Themes and categories that emerged from the data.

The majority of the participants felt that in terms of knowledge, the curri­ culum should include more information on core and trunk stability, spinal cord injury, and paediatrics, and that students need knowledge of models and frames of reference in the 1st year. The majority of the participants said that the current curriculum sufficiently prepares students for assessment, although there could be more focus on test mechanics. Participants thought that they should be better prepared for treatment, specifically activity analysis, which includes grading, how to make adaptations and how to integrate it within treatment. Participants thought it important to be taught the skill of making good use of time and prioritising intervention, which would

This theme alluded to the importance of client centredness, self-directed learning and confidence of the student.

Participants all agreed that confidence, adaptability and willingness to learn are essential attitudes for students to develop to ensure good clinical practice. It is suspected that having confidence may result in students being more handson in dealing with patients, thus improving the quality of service that they provide. Participants thought that the attitude of clinical therapists towards the curriculum and lecturers’ attitudes towards the students are also important aspects to consider in the training of students in the field of neurology: ‘I felt unsure and a little bit anxious, which automatically carries over to the patient and then the patient didn’t want me to touch him and then that was not good at all.’

help them to prepare for resource constraints of limited time with patients. They also felt that the knowledge of their own role and the scope of other team members’ roles are important for clinical practice: ‘The techniques we learn are good to know but … we want to see how they are applied in the activity.’

‘In terms of spinal cord, because you have to make so many adaptations, you have to think very creative, to think if your patient can’t supinate, how else is he going to dress himself … .’

‘Communication skills with other profes sionals, especially, uhm, working with team members. It is really helpful to work with a physio.’

This theme focused on the availability of resources within the clinical area and the limited time for intervention.

The greatest resource constraint identified by participants was limited time spent with patients owing to the high patient turnover, limited funds available to patients to attend outpatient services, and the scheduling of time for treatment, taking into consideration other team members: ‘The reality of the high turnover I think is a very scary thing and it affects your therapy a lot more than you think it does and I didn’t feel like we were equipped for that.’

‘A resource constraint is, in terms of wheel­ chairs, a lot of the hospitals have a wheelchair shortage, and even the school I worked at.’

Theme 4: Factors influencing optimal learning experiences This theme focused on the importance of evidence-based practice, practical exposure, and a closer interface between academics and the clinical areas.

The majority of participants felt that it would be beneficial to have neurology lectures scheduled consecutively, i.e. taught in a learning block.

This would assist students to link aspects, allow-

March 2017, Vol. 9, No. 1 AJHPE

41

Research ing for better consolidation of the information. The participants alluded to the importance of making use of updated information sources and ensuring that the intervention taught is based on evidence-based practice.

Participants indicated that using a variety of teaching methods, including case studies, videos and shared experiences, and being given an opportunity to observe the practical application of theory, can help to facilitate transference and application of what is taught from classroom to practice in the clinical setting. Participants felt that the opportunity to practise on real patients to develop skills is essential and that the mastering of skills takes place in the clinical setting. Participants also thought that there should be ongoing communication between the university, clinical platform, students and supervisors to ensure realistic expectations of students: ‘That they clearly define what is undergraduate stuff and what they expect from us in a block because you come to the block and then they expect you to do postgrad stuff … .’

‘They give us unattached, separated pieces and they expect that when we get with our real patient all these puzzle pieces are going to come together.’

Discussion

Looking at the knowledge required for treatment, the participants did not feel adequately prepared for implementing appropriate treatment in the clinical setting. This may be because treatment knowledge is taught from the 3rd year when clinical practice has already commenced, while during the assessment of knowledge more time is allowed for learning, consolidation, and application, as it is taught in the 2nd year.[13] The participants also indicated that expectations for clinical practice differ from the theory that is taught in the classroom. It is speculated that this may be a contributing factor to why the participants do not feel adequately prepared for implementing treatment in clinical practice.

The prevailing point regarding the skills needed in practice was the participants’ feeling that they did not have adequate opportunity for practising skills on real patients before commencing clinical practice. Many of the participants felt that as the mastering of skills occurs in the clinical setting, the opportunity for clinical practice is essential. This point needs to be considered when revising the neurology curriculum. It is important to view the grading of learning opportunities to facilitate the students from classroom experience to clinical practice. A possible grading could be as follows: students learn techniques in the classroom; they practise these on peers under supervision of the lecturer in class; they shadow the lecturer in the clinical field doing the techniques; and they have an opportunity in small groups to practise techniques on patients under supervision of the lecturer – placed in a clinical setting.

Participants required more knowledge of the starting point for assessment and treatment. They felt it necessary to be skilled in working efficiently and prioritising intervention. Considering a change in the clinical picture and resource constraints, it is important for students to be innovative in creating solutions to problems. This raises the question of how to teach students to interpret referrals, taking cognisance of all the factors impacting on a particular patient. The greatest resource constraint experienced is having limited time with patients owing to high patient turnover, limited funds available to patients to attend outpatient services, and scheduling time for treatment, taking into consideration other team members. This is in line with the resource constraints expressed by Griffin.[14]

42

March 2017, Vol. 9, No. 1 AJHPE

It was stated that it is important for clinical supervisors to be understanding and have a positive attitude towards student supervision to improve the students’ clinical experiences. This reflects what was found in the study

by Chiang et al.,[6] which indicated that inadequate guidance by clinical lecturers often leads to a negative clinical experience.

Participants thought that being learning orientated will help to ensure that they are better prepared for clinical practice. As in other studies,[4,7] participants in this study unanimously felt that confidence is an essential attitude when going into a clinical placement. The study by Naidoo et al.[7] found that students’ experiences of clinical work directly relates to their degree of confidence in neurology practice.

Participants were of the opinion that transference and application of what is taught from theory to practice in the clinical setting could be facilitated by using teaching methods, such as case studies, videos, and lecturers sharing their clinical experience and demonstrating on real patients. It was suggested that it could be beneficial to teach the occupational therapy neurology curriculum together with the neurology content of preclinical subjects in a learning block, rather than spreading these out. This would allow greater opportunity for the students to be able to link all the aspects of the neurology practice together, allowing for better consolidation of the information.

Conclusion

This research suggests that the neurology curriculum should prepare students to be as well equipped as possible for the current climate of the profession in SA, and therefore should be updated and revised regularly.

The majority of the participants recommended that neurology be taught as a learning block and that students should adopt a willingness to learn.

Participants also felt that educators and therapists should maintain a positive attitude to facilitate the development of the students’ confidence.

Furthermore, clinical areas and the Division of Occupational Therapy should have clear communication to ensure alignment of what is taught and what is expected in clinical practice. While the current neurology curriculum may be viewed to have some positive features and aspects that need to be updated and revised, it may be valuable to note that, as pointed out by Tryssenaar and Perkins,[15] that students will always perceive gaps and discrepancies in training, as it is difficult to teach all skills that may be needed in occupational therapy practice. Therefore, when revising an undergraduate curriculum, it is important for educators to consider the views of relevant stakeholders to determine the most important aspects for inclusion in the revision of a curriculum.

Acknowledgements. This research was funded by the Fund for Innovation and Research into Learning and Teaching (FIRLT), SU. 1. World Health Organization. The Global Burden of Disease. 2004 update. Geneva: WHO, 2004.

2. Wittman PP. The disparity between educational preparation and the expectations of the practice. Am J Occup Ther 1990;44(12):1130-1131. http://dx.doi.org/10.5014/ajot.44.12.1130 3. Freeme JD. A proposal for an undergraduate stroke rehabilitation curriculum appropriate for South African occupationl therapy. S Afr J Occup Ther 2014;44(1):69-75.

4. McCluskey A. Collaborative curriculum development: Clinicians’ views on the neurology content of a new occupational therapy course. Aust Occup Ther J 2000;47(1):1-10.

5. Unger M, Hanekom SD. Benefits of curriculum renewal: The Stellenbosch University physiotherapy experience.

Afr J Health Professions Educ 2014;6(2):222-226. http://dx.doi.org/10.7196/ajhpe.519 6. Chiang HYA, Pang CH, Li WS, Shih YN, Su CT. An investigation of the satisfaction and perception of fieldwork experiences among occupational therapy students. Hong Kong J Occup Ther 2012;22(1):9-16. http://dx.doi.org/­ 10.1016/j.hkjot.2012.04.001 7. Naidoo D, van Wyk J, Joubert R. Are final-year occupational therapy students adequately prepared for clinical practice? A case study in KwaZulu-Natal. S Afr J Occup Ther 2014;44(3):24-28. http://dx.doi.org/10.7196/ ajhpe.2016.v8i1.536

Research 8. Rodger S, Clark M, Banks R, Oâ&#x20AC;&#x2122;Brien M, Martinez K. A national evaluation of the Australian occupational therapy competency standards: A multistakeholder perspective. Aust Occup Ther J 2009;56(6):384-392. http:// dx.doi.org/10.1111/j.1440-1630.2009.00794.x 9. Verma S, Paterson M, Medves J. Core competencies for health care professionals: What medicine, nursing, occupational therapy, and physiotherapy share. J Allied Health 2006;35(2):109-115.

10. Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Educ Today 1991;11(6):461-466. http://dx.doi.org/10.1016/0260-6917(91)90009-y 11. Peledeau N. QDA Miner: Userâ&#x20AC;&#x2122;s Guide. Montreal: Provalis Research, 2004.

12. Lincoln Y, Guba EG. Paradigmatic controversies, contradictions and emerging confluences revisited. In: Dezin NK, Lincoln YS. The Sage Handbook of Qualitative Research. 4th ed. Thousand Oaks, CA: Sage, 2011:97-128.

13. Stellenbosch University Occupational Therapy Department. Occupational Therapy Neurology Outcomes. Cape Town: Stellenbosch University, 2014.

14. Griffin SD. Short bed stays: Their effect on occupational therapy services in teaching hospitals. Arch Phys Med Rehabil 1993;74:1087-1090.

15. Tryssenaar J, Perkins J. From student to therapist: Exploring the first year of practice. Am J Occup Ther 2001;55(1):19-27. http://dx.doi.org/10.5014/ajot.55.1.19

March 2017, Vol. 9, No. 1 AJHPE

43

Research

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Exploration of high-fidelity simulation: Nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting T Munangatire,1 BScNS, MPhil (HSE); N Naidoo,2 MMedSci, MEd 1

Paray School of Nursing, Thaba Tseka, Lesotho

2

Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: T Munangatire (takamunangatire@gmail.com)

Background. Simulations are defined as situations where models are used for practice and to gain experience that will enhance students’ practical skills. The use of simulations in clinical skills training can stimulate deep learning and help students to bridge the gap between theory and practice in nursing. This has been revealed in many studies where simulations positively impacted on clinical decision-making and patient care, and there has been great interest in the use of simulation in nurse training. However, the introduction of technologically driven simulators, especially in resourceconstrained settings, has been met with mixed feelings.

Objective. To explore the perceptions and experiences of nurse educators in using high-fidelity simulation (HFS) in teaching.

Methods. A qualitative case study design was utilised. Seven educators at a school of nursing, which has HFS, participated in a focus group discussion.

Data were thematically analysed.

Results. Four themes emerged from the educators’ experiences and perceptions. The use and benefits of HFS were generally accepted by educators.

They valued its positive impact on learning outcomes in learners and the ability to simulate more complex scenarios during training. Lack of prior planning, inadequate training and lack of resources impacted negatively on the effective use and implementation of HFS. Conclusion. The results indicated that nurse educators perceived HFS as a learning pedagogy that can improve students’ learning outcomes if used effectively. They believed that to realise the potential of HFS, more support should be provided through training, the availability of necessary resources, and improved planning and organisation.

Afr J Health Professions Educ 2017;9(1):44-47. DOI:10.7196/AJHPE.2017.v9i1.739

Simulation is the art and science of recreating a clinical scenario in an artificial setting to allow for deliberate teaching and learning of clinical skills.[1] Examples of simulation include the use of standardised patients, models and mannequins, which may be low, medium or high fidelity. A high-fidelity simulator, such as a state-of-the-art mannequin, can be programmed to produce physiological functions, such as palpable pulses, voices and abdominal sounds through computer interfaces.[2] Changes in training of nurses and the progressive culture of teaching and learning support the use of simulation to maximise and enhance clinical skills training.[2] High-fidelity simulation (HFS) uses advanced technology to produce most human physiological responses in a mannequin, while medium-fidelity simulation provides only basic human responsive functions, with low-fidelity simulation mannequins being static and non-responsive.[2] While there has been an explosion of research on HFS in the developed world, there are relatively few studies emerging from the developing world.[3] Current evidence shows that the use of HFS in nurse training institutions has been met with mixed reactions, which has impacted on the use of HFS at these institutions.[4] In cases where HFS has been well received and effectively used, it has resulted in improved learning of clinical skills.[5] It therefore stands to reason that an institution that introduces HFS will benefit from establishing its acceptability among educators. The benefits of knowing how educators perceive the value of HFS will give an indication of the likelihood of it being used in teaching and training.

44

March 2017, Vol. 9, No. 1 AJHPE

Against a background of slowly improving health outcomes, Lesotho acquired HFS with the hope of improving the quality of nursing skills training. HFS equipment was distributed to six nursing schools in Lesotho.

For HFS to facilitate improved clinical skills learning outcomes in these institutions, it has to be accepted and effectively used by nurse educators and students. This study was conducted to explore nurse educators’ perceptions and experiences of using HFS in learning clinical skills in one of the resource-constrained schools of nursing.

Literature review

HFS as a learning pedagogy

As a pedagogical strategy, HFS is supported by learning theories, including constructivism, experiential learning and situated cognition. When making use of HFS during learning sessions, students practise skills by means of clinical scenarios, where they construct meaning out of these scenarios through deliberate practice. Students need to understand that the practice that takes place in the clinical skills laboratory later needs to be transferred to the clinical area. Therefore, theories suggest that HFS as a teaching and learning strategy shifts learning from a predominantly behaviourist pedagogy (teacher centred) towards more student-centred approaches.[2] The student-centred approaches supported by HFS include experiential learning and situated cognition, where HFS allows students to make mistakes in the simulation and then transform and apply the learned experiences to tasks,

Research interactions and cultural dynamics in different situations and contexts, such as various departments of the clinical area.[7,8]

Theoretical framework

In summary, this study explored the perceptions and experiences of nurse educators’ use of HFS in teaching, as its acceptability by educators as a teaching strategy is important for effective use.

The National League of Nursing Framework (NLNF), developed by Jeffries,[1] is important in understanding the concepts that influence the acceptability of HFS.[9] This framework suggests that effective HFS use depends on several factors (Fig. 1). Jeffries[1] acknowledges the role of the teacher as a designer, supervisor and implementer of simulation in nurse education. To ensure successful use of simulation, the teacher must have a good perception of simulation, be comfortable using the technology, and be a good facilitator and evaluator of the learning process.[1] The NLNF has been endorsed and utilised in evaluating simulation use by several researchers ahead of other models, such as the Expert Performance Approach.[1,10] Therefore, the Jeffries[1] model remains the most relevant and was used to guide this study.

Methods

Constructs shaping experiences and perceptions

Data were collected during a once-off focus group discussion, which was guided by an interview schedule adapted from Krueger and Caseys’s[15] guidelines on focus group interviews. Adaptations to the guidelines were made based on literature and the opinions of two researchers who validated the semi-structured interview guide. The researcher and the assistant prepared the venues and seating arrangement in a semicircle to promote interaction.

The researcher moderated the focus group discussion, while the assistant managed digital voice recorders and took notes. Anonymity was ensured by identifying participants by number rather than name. The focus group discussion lasted for 55 minutes.

To ensure the credibility of the study, the methods were well described, and the data were recorded and transcribed verbatim by the researcher. The co-researcher and participants checked the transcription for accuracy.

Using HFS in teaching presents educators with mixed experiences – some exciting and some frustrating. The experiences are shaped by constructs, such as planning for simulation, training on how to use simulation, the availability of resources and motivation for using simu­lation.[4] Educators’ experiences of using HFS influence their perceptions and adoption of HFS in teaching.[4] Adoption of HFS as pedagogy for clinical skills without carefully planning for its use creates a negative perception among educators.[10,11] Issen­ berg et al.[10] contend that HFS is complex, and for effective use it requires excellent planning and organisational contextualisation. Furthermore, lack of time, support, appropriate equipment and fear of using HFS simulation as a pedagogy create negative perceptions, and result in underutilisation.[12] Findings to date suggest that there are mixed perceptions among lecturers regarding the impact on training of using HFS in teaching.[10] In Dowie and Phillips’[13] study, 90% of educators were using HFS, although only 35% of them had been trained in its use. However, Schlairet’s[14] findings revealed that only 50% of trained educators were using HFS in teaching. This suggests that motivation and the level of support from colleagues and administrative staff influence educators’ use of HFS rather than training alone.[11]

Outcomes

cher Tea • Demographics

• Active learning • Feedback • Student/faculty interaction

Studen t

• Learning (knowledge) • Skill performance • Learner satisfaction • Critical thinking • Self-confidence

• Programme • Level • Age • Collaboration • High expectations • Diverse learning • Time on task

Educational practices

Fig. 1. National League of Nursing Framework.[1]

Simulation design characteristics • Objectives • Fidelity • Problem-solving • Student support • Debriefing

Research design

A descriptive, qualitative case study design was utilised to explore nursing educators’ perceptions and experiences in a focus group discussion.

Population and sample

All 10 educators who teach at our nursing school were identified as the population for this case study. From this population, a sample of seven educators was purposively selected to participate in the study, based on the inclusion criteria stated above. These seven educators were selected because they were using HFS in their teaching.

Data collection

Data analysis

The data recordings were transcribed by the researcher, who organised the data into paper records for ease of thematic analysis. Thematic analysis was suitable for this descriptive qualitative study because it is not closely tied to any theory of qualitative research, and allows for flexibility of analysis, resulting in the detailed description of data.

Data analysis was an iterative and reflexive process to ensure richness of the analysis. It commenced with the coding process, which involved recognising (seeing) an important moment and encoding (seeing it as something) it prior to a process of interpretation. The encoding organised the data in such a way that themes could be identified and developed. The encoding process resulted in the development of a codebook, which served as a data management tool for organising segments of similar or related text to assist in interpretation. As a way of testing the reliability of the codes, the researcher invited the co-researcher to also code the transcripts; the co-researcher’s codes were found to be similar to those of the researcher.

Results

This study explored nursing educators’ experiences and perceptions of using HFS in teaching. Participants had positive and negative experiences and perceptions of HFS, which are described under the themes that emerged from the focus group discussion data: planning, training, resources, benefits and limitations (Table 1).

March 2017, Vol. 9, No. 1 AJHPE

45

Research Discussion

This study explored nurse educators’ perceptions and experiences of HFS in teaching to establish how acceptable HFS would be in a resource-limited setting.

Participants perceived HFS to be an important teaching strategy, but pointed out that effective implementation requires careful planning.

Hyland and Hawkins[9] and Adamson[11] noted that lack of adequate preparation for the introduction of HFS results in non-use. However, in this study, lack of planning did not impede the use of HFS in teaching clinical skills.

Lack of training did not discourage the use of HFS for teaching, as educators were highly motivated and willing to teach using HFS. They appreciated the benefits of being able to simulate rare scenarios, teaching problem-solving skills and improving student confidence.[4] There is a need to support this motivation and willingness through formally training educators, which can potentially promote HFS use and destigmatise the

educators’ experiences and perceptions of not using or improperly using HFS.[5,7,13] Training will capacitate educators to use HFS strategically and to maximise its benefits in teaching.[6,12] Despite challenging experiences due to lack of formal training, educators used HFS because they believed it to be a worthwhile investment that could improve student learning outcomes in resource-limited settings.

HFSs are some of the resources required in teaching clinical skills in nursing, but cannot be used in isolation.[12] Additional resources, such as time and appropriate equipment, are needed to facilitate effective teaching using HFS, otherwise educators become frustrated and discouraged from using it.[13] The need for these resources, together with technological support in the simulation room, was clearly verbalised in our study, confirming the need to holistically plan and procure all resources necessary to effectively operationalise HFS in teaching. In this way, nurse educators will have satisfying experiences and consequently readily accept the use of HFS in teaching.

Table 1. Findings Theme

Descriptors

Quote

Planning

Some participants were not pleased with the implementation of HFS at the school and felt that the resource had been provided without giving due recognition to other priority needs. Some people were frustrated that HFS had been introduced without consultation. They explained that the frustration was evident in the low use of HFS as a teaching resource

‘It is an excellent teaching device but it is not meeting what we want at that point in time.’ (Educator 3) ‘… they suddenly just bring those things [HFS] to us.’

(Educator 3) ‘Because if really our institutions cried for those simulators, we couldn’t be facing challenges in terms of utilising them.’ (Educator 1)

Training

Most participants reported that they were excited about the short orientation or ‘training session’ that they were given when HFS was initiated. Their excitement turned to disappointment, however, when they realised that they lacked adequate training and were not able to fully use HFS with the initial level of training

‘When we were first oriented on how to use high fidelity simulation, I was so excited and I will believe that I will be able to use it and it will enhance, ahh my teaching … .’ (Educator 6)

Resources

The participants perceived HFS use as a demanding pedagogy, requiring technical know-how, careful planning, time, teamwork, and innovation in creating simulation scenarios for effective implementation Participants emphasised that there was insufficient equipment, both in quantity and type. Additional resources were needed, such as mannequins, part-task trainers, technical support, monitoring cameras and dedicated space for projection, where students may observe demonstrations without being present in the simulation rooms

‘… I might not have the time for preparation and planning because I might have to feed the doll information … .’ (Educator 2) ‘My recommendation is as I mention the issue of technical somebody like in a school lab … .’

(Educator 5) ‘… high fidelity wouldn’t be part of our high priority needs.’ (Educator 4)

Benefits

Participants were strongly in favour of the use of HFS because of students’ positive learning outcomes and improved confidence, and because they felt that HFS promoted skills transfer from the lecturer to the students

‘… simulators help build up the confidence and polish up the skill … .’ (Educator 3) ‘… simulator helps in the transfer of skill from the instructor to the students.’ (Educator 3)

Some reported that HFS allows simulation of uncommon procedures, facilitating traditionally difficult-to-teach skills, such as problem-solving and critical thinking

‘… the high fidelity ones are more effective in other clinical situations that are rare … .’ (Educator 1)

Participants felt that the ability to transfer skills from the simulation to the clinical area may not be easy

‘… that thing is not a person, when the student is practising on that thing it might be easy.’ (Educator 3)

Some participants noted that there were limitations to the level of fidelity or the extent to which HFS resembles a real human being. HFS was, for example, able to imitate a human being physically, but failed to do so psychologically

‘… they are more effective on the skills part, but the attitudes, nurse-patient relationship, it’s not very effective … .’ (Educator 5) ‘It’s like you cannot do everything on high fidelity, there is a limited number, that limitation frustrated me.’ (Educator 5)

Limitations

46

March 2017, Vol. 9, No. 1 AJHPE

Research Previous studies have revealed that educators view HFS as an effective teaching strategy, but noted that it has a number of limitations.[13] This resonates well with the findings in our study, where educators perceive HFS as a beneficial teaching strategy, even though it has inherent limitations. Our study found that educators believe that HFS improves learning outcomes in simulation, although the nurse educators thought that it is difficult to transfer these skills to actual practice. Young and Shellenbarger’s[6] findings align with these findings, which showed that nurse educators’ use of HFS depends on whether or not they are comfortable using the technology and believe that HFS promotes learning and improves learning outcomes.

However, its use is challenging owing to the complexities associated with working with simulation equipment.

Nurse educators view HFS as a worthwhile strategy for use in teaching, and the reported benefits of its use act as a motivation for them to adopt it. This suggests that nurse educators are in favour of using HFS in teaching clinical skills.

Poor utilisation of HFS by educators may stem from negative experiences surrounding the use of simulation. Poor planning in introducing HFS, lack of resources to support its use, inadequate training, and the limitations of HFS in teaching result in negative experiences and hence poor utilisation by educators. To have HFS accepted and used effectively, it is essential to create adequate implementation plans, acquire the necessary additional resources, and provide comprehensive training for educators.

Conclusion

HFS is perceived as a valuable teaching strategy that improves students’ competence, motivating educators to use HFS in teaching clinical skills. However,

if it is not properly implemented, educators may experience frustration and disappointment, with the result that the benefits of HFS may be diminished, leading to under-utilisation or non-use. Therefore, setting up HFS and implementing it should be carefully planned, and educators should be formally trained and given technical support and any additional resources needed for teaching students to use HFS. These measures will increase the adoption of HFS which, in turn, may improve the training of nurses.

1. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect 2005;26(2):96-103.

2. Bux A. Nurses’ perceptions of the usefulness of high fidelity simulation technology in a clinical education program. ProQuest 2009;503.

3. Davies J, Alinier G. The growing trend of simulation as a form of clinical education: A global perspective. Int Para Prac 2011:1(2):58-62. http://dx.doi.org/10.12968/ippr.2011.1.2.58 4. Reid-Searl K, Happell B, Vieth L, et al. High fidelity patient silicone simulation: A qualitative evaluation of nursing students’ experiences. Collegian 2012;19(2):77-83.

5. Cooper S, Cant R, Porter J, et al. Simulation based learning in midwifery education: A systematic review. Women Birth 2012;25(2):64-78. http://dx.doi.org/10.1016/j.wombi.2011.03.004 6. Young PK, Shellenbarger T. Interpreting the NLN Jeffries framework in the context of nurse educator preparation.

J Nurs Educ 2012;51(8):422-428. http://dx.doi.org/10.3928/01484834-20120523-02 7. Paige JB, Daley BJO. Situated cognition: A learning framework to support and guide high-fidelity simulation.

Clin Simul Nurs 2009;5(3):e97-e103. http://dx.doi.org/10.1016/j.ecns.2009.03.120 8. Lea SJ, Stephenson D, Troy J. Higher education students’ attitudes to student-centred learning: Beyond ‘educational bulimia’? Studies Higher Educ 2003;28(3):321-334. http://dx.doi.org/10.1080/03075070309293 9. Hyland JR, Hawkins MC. High-fidelity human simulation in nursing education: A review of literature and guide for implementation. Teach Learn Nurs 2009;4(1):14-21. http://dx.doi.org/10.1016/j.teln.2008.07.004 10. Issenberg BS, McGaghie WC, Petrusa E, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Med Teach 2005;27(1):10-28. http://dx.doi.org/­ 10.1080/01421590500046924 11. Adamson K. Integrating human patient simulation into associate degree nursing curricula: Faculty experiences, barriers, and facilitators. Clin Simul Nurs 2010;6(3):e75-e81. http://dx.doi.org/10.1016/j.ecns.2009.06.002 12. Garrett B, MacPhee M, Jackson C. High-fidelity patient simulation: Considerations for effective learning. Nurs Educ Perspect 2010;31(5):309-313.

13. Dowie I, Phillips C. Supporting the lecturer to deliver high-fidelity simulation. Nurs Standard 1987;25(49):35-40. http:// dx.doi.org/10.7748/ns2011.08.25.49.35.c8651 14. Schlairet MC. Simulation in an undergraduate nursing curriculum: Implementation and impact evaluation.

J Nurs Educ 2011;50(10):561-568. http://dx.doi.org/10.3928/01484834-20110630-04 15. Krueger RA, Casey MA. Designing and conducting focus group interviews. Social Anal Select Tools Techn 2002;4(23):4-24.

March 2017, Vol. 9, No. 1 AJHPE

47

CPD questionnaire March 2017 True (A) or false (B): South-South Cooperation in health professional education: A literature review 1. Globally, there is consensus on the effectiveness of different implementation models of aid.

2. The authors acknowledge three distinct funding models: the Development Assistance Committee (DAC) model, the Arab model and the Southern model.

An integrated literature review of undergraduate peer teaching in allied health professions 3. Despite the small number of relevant articles included in the review, there was clear consensus on the principles of peer-assisted learning (PAL).

4. Findings by Hammond et al. showed that PAL sessions should be informally organised and not incorporated in the timetable and curriculum of students.

Developing a service-learning module for oral health: A needs assessment 5. Reflection has been identified as a key principle of service learning (SL) and is considered as the glue that holds service and learning together.

6. The authors define SL as ‘refers to the interactions and processes through which the expertise of the institution in the areas of teaching, learning and research are applied to develop and sustain society’.

Barriers to continuous professional development participation for radiographers in Kenya 7. In this research, it was found that a minority of diagnostic radiographers who were registered with the Society of Radiography in Kenya (SORK) were enrolled in a CPD programme.

8. Time constraints were not identified by participants as major barriers to CPD participation.

Specialty choice among dental students in Ibadan, Nigeria 9. Job security is not one of the factors identified as influencing dental students’ and graduates’ choice of dental specialty.

10. Personal interest was the major influential factor of career choice for both men and women.

Pioneering small-group learning in Tanzanian emergency medicine: Investigating acceptability for physician learners 11. The finding of this research revealed that students preferred lectures as a teaching method for improving medical knowledge.

12. ‘Interactivity of seminar to learn physical/procedural skills’ was found to be an ineffective aspect of small-group learning.

Self-directed learning: Status of final-year students and perceptions of selected faculty leadership in a Nigerian medical school – a mixed analysis study 13. The three skills considered integral to self-regulated learning include metacognition, self-teaching and cognition.

14. A key concept of cognitive load theory is that the cognitive load should match the working memory of the learner.

Self-regulated learning: A key learning effect of feedback in a problem-­based learning context 15. This study noted that students’ interest in a subject influences their selfregulation.

16. The role of the lecturer in problem-based learning (PBL) is to guide students and promote sharing, interaction and exchange of ideas towards constructing new knowledge.

Occupational therapy students’ perspectives on the core competencies of graduates to practise in the field of neurology 17. Participants in this study felt adequately prepared for implementing the appropriate treatment while in their clinical setting.

18.

Previous research has shown that inadequate guidance from clinical­ supervisors is linked to negative clinical experiences.

Exploration of high-fidelity simulation: Nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting 19. Time and appropriate equipment were acknowledged as important to effective teaching using high-fidelity simulation (HFS).

20.

There have been relatively few studies on HFS emerging from the developing world.

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: MDB015/170/02/2017 (Clinical)

48

March 2017, Vol. 9, No. 1 AJHPE