AJHPE Vol 9, No 3 (2017) by HMPG

African Journal of Health

Professions Education June 2017, Vol. September 2017, 9 No. Vol.29, No. 3

Scholarship of Africa for Africa

ISSN 2078 - 5127

AJHPE African Journal of Health Professions Education September 2017, Vol. 9, No. 3

EDITORIAL 91 Strengthening health professions education and training: The power of evidence-based approaches G Mubuuke

SHORT COMMUNICATION

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 Jose Frantz University of the Western Cape Jacqueline van Wyk University of KwaZulu-Natal

92 Health sciences students’ contribution to human resources for health strategy: A rural health careers day for grade 12 learners in the North West Province of South Africa N O Mapukata, I D Couper, A R Dreyer, M Mlambo

ASSOCIATE EDITORS Francois Cilliers University of Cape Town

SHORT RESEARCH REPORT

Patricia McInerney University of the Witwatersrand

94 A quick needs assessment of key stakeholder groups on the role of family medicine in Zambia J Sanders, M Makasa, F Goma, E Kafumukache, M S Ngoma, S Nzala

RESEARCH

Rhena Delport University of Pretoria

Ntombifikile Mtshali University of KwaZulu-Natal Anthea Rhoda University of the Western Cape

98 Registrar wellness in Botswana: Measuring burnout and identifying ways to improve wellness K D Westmoreland, E D Lowenthal, R Finalle, L Mazhani, M Cox, J C Mwita, S B Mphele, C E Turner, A P Steenhoff

Michael Rowe University of the Western Cape

103 Assessment of the educational environment of physiotherapy students at the University of Rwanda using the Dundee Ready Educational Environment Measure (DREEM) G Urimubenshi, J Songa, F Kandekwe

Susan van Schalkwyk Stellenbosch University

107 Standardised patient-simulated practice learning: A rich pedagogical environment for psychiatric nursing education A Jacobs, I Venter 111 Understanding student early departure from a Master of Public Health programme in South Africa T Dlungwane, A Voce, R Searle, J Wassermann 116 Postgraduate trainees’ perceptions of the learning environment in a Nigerian teaching hospital P I Idon, I K Suleiman, H O Olasoji, Z Mustapha, H M Abba 123 Radiation safety requirements for training of users of diagnostic X-ray equipment in South Africa B van der Merwe, S B Kruger, M M Nel 128 Training requirements for the administration of intravenous contrast media by radiographers: Radiologists’ perspective G G V Koch, L D Swindon, J D Pillay 133 Perceptions of the impact of an advanced training programme on the management skills of health professionals in Gauteng, South Africa J Mutyabule, F Senkubuge, D Cameron, V Pillay, P Petrucka 138 A peer evaluation of the community-based education programme for medical students at the University of Zimbabwe College of Health Sciences: A southern African Medical Education Partnership Initiative (MEPI) collaboration D Michaels, I Couper, M S Mogodi, J G Hakim, Z Talib, M H Mipando, M M Chidzonga, A Matsika, M Simuyemba

Marietjie van Rooyen University of Pretoria

Elizabeth Wolvaardt University of Pretoria

HMPG

CEO and PUBLISHER Hannah Kikaya Email: hannahk@hmpg.co.za EXECUTIVE EDITOR Bridget Farham MANAGING EDITORS Claudia Naidu Naadia van der Bergh TECHNICAL EDITORS Emma Buchanan Kirsten Morreira Paula van der Bijl PRODUCTION MANAGER Emma Jane Couzens DTP & DESIGN Clinton Griffin Travis Arendse CHIEF OPERATING OFFICER Diane Smith I Tel. 012 481 2069 Email: dianes@hmpg.co.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, Mrs H Kikaya, Dr M Mbokota, Dr G Wolvaardt ISSN 2078-5127

144 Fifth-year medical students’ perspectives on rural training in Botswana: A qualitative approach P Kebaabetswe, T Arscott-Mills, K Sebina, M B Kebaetse, O Makgabana-Dintwa, L Mokgatlhe, G Tawana, D O Mbuka, O Nkomazana 148 Quantity and quality of written feedback, action plans, and student reflections before and after the introduction of a modified mini-CEX assessment form R M Djajadi, M Claramita, G R Rahayu 153 Upskilling nursing students and nurse practitioners to initiate and manage patients on ART: An outcome evaluation of the UKZN NIMART course R Mngqibisa, M Muzigaba, B P Ncama, S Pillay, N Nadesan-Reddy

CPD questionnaire

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Editorial

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

Strengthening health professions education and training: The power of evidence-based approaches Health professions are anchored in the education and training that underpin them; such training continues to evolve with support from the growing evidence base.[1] Health professions education (HPE) focuses on the theories, principles, concepts, methods, skills and attitudes specifically required for the education and training of health professionals within the specific learning environment of hospitals or communities. HPE also aims at encouraging the application of educational principles in the unique context of health professions and healthcare settings. The aforementioned reasons typically differentiate HPE from more general educational training. In developed and developing countries, greater variety in skills within health professions is needed if healthcare is to be made accessible to all.[1] Furthermore, to be able to contribute to the advancement of the different health professions, today’s health professionals have to be highly skilled and knowledgeable in a number of competencies.[2] This implies that health professionals must be educated and trained to the required high standards to address the ever-dynamic community health needs. Improving the quality of training is, therefore, an important contribution to strengthening health systems.[3] However, such improvement in training needs to be supported by good evidence-based practices that are feasible, especially in institutions with limited resources. There is a global drive to expand the numbers and competencies of health professionals being trained in response to societal needs.[4] In addition, major reforms and innovations are taking shape in the field of HPE.[1] Such reforms include student-centred learning, interprofessional education, community-based education, competency-based education, e-learning and service-learning.[5,6] To implement these reforms, faculty in health professions training institutions not only need to improve the existing training methods, but also innovate other feasible methods to improve training by means of evidence-based scholarly approaches. AJHPE has had a strong tradition of publishing scholarly original research and reviews related to improving the training and performance of health professionals, using evidence-based practices. In this issue, the use of scholarly evidence to improve the education and training of health professionals as well as strengthening existing systems resonates through all the articles, which can generally be grouped into three over-arching themes. The first theme is about enhancing the learning environment, which is reflected in a number of articles. For example, the article by Westmoreland et al.[7] examines the improvement of the learning environment and wellness of trainee registrars to prevent burnout and exhaustion, while Urimubenshi et al.[8] explore solutions from students’ perceptions on how to improve their learning environment. The article by Jacobs and Venter[9] speaks to improving the clinical learning environment using standardised patient simulation. Dlungwane et al.[10] and Idon et al.[11] explore means of improving the learning environment of post graduate trainees. The important idea of using feedback to improve the clinical learning environment of students is also discussed in this issue. The second theme relates to improving skills and competencies of student trainees to address the prevailing needs. A key factor is the need to identify gaps within the skills and competencies of health professionals and design appro priate training interventions using an evidence-based approach. For example, the articles by Van der Merwe et al.,[12] Sanders et al.[13] and Koch et al.[14] indicate skills gaps and appropriate training interventions to enhance trainee skills.

The last theme in the current issue is the value attached to community-based education, which in HPE has been reported to be an excellent mechanism of promoting service-learning[15] and stimulating the interest of students to work in rural and under-served areas.[16] This is reflected through aspects of community-based training and how it can be improved to promote a more positive student experience. Therefore, the scholarly research work in this edition of AJHPE demonstrates that improving the training of health professionals can indeed be fanned by an evidence-based foundation. In Africa, many institutions have adopted and adapted teaching and learning approaches from Europe and the USA. Taking on these approaches, as a whole, has proved to be a challenge owing to our own systemic and contextual differences. Therefore, while external forces may drive evidence-based practice in HPE, there is a need for individual institutions to generate local evidence of what works best through scholarly and empirical inquiry. This will fuel and sustain innovations in HPE in Africa. G Mubuuke School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda gmubuuke@gmail.com

1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/S01406736(10)61854-5 2. Bhutta ZA, Lassi Z, Pariyo G, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. Geneva: Global Health Workforce Alliance, 2010. 3. Hung W. All PBL starts here: The problem. Interdiscipl J Problem-Based Learn 2016;10(2). https://doi. org/10.7771/1541-5015.1604 4. Xue H, Qian J, Wang L, et al. 3C3R modified PBL pediatric teaching of Chinese medical students. PLoS ONE 2013;8(5):1-9. https://doi.org/10.1371/journal.pone.0063412 5. Amoako-Sakyi D, Amonoo-Kuofi H. Problem-based learning in resource-poor settings: Lessons from a medical school in Ghana. BMC Med Educ 2015;15:221. https://doi.org/10.1186/s12909-015-0501-4 6. Burch VC, Sikakana CNT, Yeld N, Seggie JL, Schmidt HG. Performance of academically at-risk medical students in a problem-based learning programme: A preliminary report. Adv Health Sci Educ 2007;12(3):345-358. https://doi. org/10.1007/s10459-006-9006-6 7. Westmoreland KD, Lowenthal ERD, Finalle R, et al. Registrar wellness in Botswana: Measuring burnout and identifying ways to improve wellness. Afr J Health Professions Educ 2017;9(3):98-102. https://doi.org/10.7196/ AJHPE.2017.v9i3.881 8. Urimubenshi G, Songa J, Kandekwe F. Assessment of the education environment of physiotherapy students at the University of Rwanda using the Dundee Ready Educational Environment Measure (DREEM). Afr J Health Professions Educ 2017;9(3):103-106. https://doi.org/10.7196/AJHPE.2017.v9i3.828 9. Jacobs A, Venter I. Standardised patient-simulated practice learning: A rich pedagogical environment for psychiatric nursing education. Afr J Health Professions Educ 2017;9(3):107-110. https://doi.org/10.7196/AJHPE.2017.v9i3.806 10. Dlungwane T, Voce A, Searle R, Wassermann J. Understanding student early departure from a Master of Public Health programme in South Africa. Afr J Health Professions Educ 2017;9(3):111-115. https://doi.org/10.7196/AJHPE.2017. v9i3.793 11. Idon PI, Suleiman KI, Olasoji HO, Mustapha Z, Abba HM. Postgraduate trainees’ perceptions of the learning environment in a Nigerian teaching hospital. Afr J Health Professions Educ 2017;9(3):116-122. https://doi. org/10.7196/AJHPE.2017.v9i3.786 12. Van der Merwe B, Kruger SB, Nel MM. Radiation safety requirements for training of users of diagnostic X-ray equipment in South Africa. Afr J Health Professions Educ 2017;9(3):123-127. https://doi.org/10.7196/AJHPE.2017.v9i3.691 13. Sanders J, Makasa M, Goma F, Kafumukache E, Ngoma MS, Nzala S. A quick needs assessment of key stakeholder groups on the role of family medicine in Zambia. Afr J Health Professions Educ 2017;9(3):94-97. https://doi. org/10.7196/AJHPE.2017.v9i3.831 14. Koch GGV, Swindon LD, Pillay JD. Training requirements for the administration of intravenous contrast media by radiographers: Radiologists’ perspective. Afr J Health Professions Educ 2017;9(3):128-132. https://doi.org/10.7196/ AJHPE.2017.v9i3.809 15. Mubuuke AG, Oria H, Dhabangi A, Kiguli S, Sewankambo NK. An exploration of undergraduate medical students’ satisfaction with faculty support supervision during community placements in Uganda. Rural Remote Health 2015;15(4):3591. 16. Crampton PES, McLachlan JC, Illing JC. A systematic literature review of undergraduate clinical placements in underserved areas. Med Educ 2013;47(10):969-978. https://doi.org/10.1111/medu.12215

Afr J Health Professions Educ 2017;9(3):91. DOI:10.7196/AJHPE.2017.v9i3.1002

September 2017, Vol. 9, No. 3 AJHPE

Short Communication

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

Health sciences students’ contribution to human resources for health strategy: A rural health careers day for grade 12 learners in the North West Province of South Africa N O Mapukata,1 MSc (Health Care Management), MSc (Med); I D Couper,2 MB BCh, MFamMed, FCFP (SA); A R Dreyer,1 MPH; M Mlambo,1 PhD 1

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

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

Corresponding author: N Mapukata (ntsiki.mapukata@wits.ac.za)

Context and setting

South Africa (SA) has made significant strides towards ensuring that the profile of learners admitted to its eight medical schools reflects the demographics of the country. Yet, despite these efforts, SA is still plagued by human-resource challenges within the health sector, with the majority of healthcare professionals preferring to work in urban areas.[1] The Wits Initiative for Rural Health Education (WIRHE) scholarship is one of the programmes that was established by the Centre for Rural Health (CRH) as a response to the workforce challenges facing rural areas of SA. This programme provides opportunities to students from previously disadvantaged rural communities to register for professional degrees offered by the faculties of health sciences at any of the three medical schools in Gauteng Province: the universities of the Witwatersrand, Pretoria and Sefako Makgatho (previously Medunsa).[2] As such, the launching of the first Rural Careers Day in the North West Province was informed by the experiences of managing the WIRHE scholarship programme, which highlighted the challenges faced by students from rural communities who try to gain access to institutions of higher education.[3] This report describes the Wits CRH experience of organising a student-led rural health careers day as a pilot project, and an evaluation thereof based on the experiences of the participating students and learners.

Why the idea was necessary

We recognised the effectiveness of student-learner mentorship based on previous experiences where Wits medical students were required to provide input about careers in rural high schools in the Bojanala District of the North West Province. Health sciences students are seldom given the opportunity to engage with high school learners in a structured programme. The hosting of a careers day in a rural district was initiated to create and strengthen an awareness of and enthusiasm for careers in the health sciences among grade 12 rural high school learners.

What was done

Twenty-four senior health sciences students volunteered to facilitate a series of mini-workshops on career options, funding opportunities and healthpromotion topics for learners from 85 high schools in Ngaka Modiri Molema District in the North West Province. A total of 224 top-five rural learners completed a self-administered questionnaire once they had completed their rotation through all the stations to evaluate their views of the day.

Results and impact

Feedback from the high school learners demonstrated that they became better informed about career options in the health sciences fields (93%).

September 2017, Vol. 9, No. 3 AJHPE

Most learners indicated that they would recommend the day’s activities to their peers (97%). The highest career preference score was for medicine (94%) (Fig. 1). Of the health-promotion stations, substance abuse received the highest ranking (80%) compared with the other topics, including HIV/ AIDS, sexually transmitted infections and teenage pregnancy. Learners perceived the applications and funding station to be ‘informative’ (80%), although they indicated a need for additional information on funding. By engaging learners on health-promotion topics related to their sexual health and life choices, they may have benefited from the exposure and may even develop an appreciation for primary healthcare-intervention strategies and the role of universities at the community level. Through designing and implementing programmes that link students to communities, universities have the potential to contribute positively to the realisation of healthcare goals in rural communities. Acknowledgements. We would like to extend our appreciation to the Wits students who joined us as volunteers, many of whom have completed their studies, and the Ngaka Modiri Molema District for its role and contribution on the Rural Careers Day. Author contributions. NM: project director and prepared the initial draft; IDC, ARD, MM: contributed to the project design, participated in the review and contributed to the final draft. Funding. Partial funding was received from the CSI Division: Toyota South Africa. Conflicts of interest. None.

Q4h Radiography (n=195)

Q4g Medicine (n=190)

Q4f Dentistry (n=160)

Q4e Physiotherapy (n=188)

Q4d Physiology (n=207)

Q4c Pharmacy (n=194)

Q4b OT (n=200)

Q4a Clin As (n=184)

80 0

100

Learners, n

Fig. 1. Learners’ rating of the relevance of each career choice station. (Q = question; OT = occupational therapy; Clin As = clinical associate.)

Short Communication 1. Khan T, Thomas LS, Naidoo S. Analysing post-apartheid gender and racial transformation in medical education in a South African province.Â Global Health Action 2013;(6)10. https://doi.org/10.3402/gha.v6i0.19810 2. Ross AJ, Couper ID. Rural scholarship schemes: A solution to the human resource crisis in rural district hospitals. S Afr Fam Pract 2004;46(1):5. https://doi.org/10.1080/20786204.2004.10873025 3. Sondzaba N, Couper I. WIRHE scholarship â&#x20AC;&#x201C; a case study of recruitment, support and retention of a rural workforce in North West. In: Conference Proceedings: Celebrating Innovative Health Management Conference, Cape Town, 20 - 30 June 2011. https://uct-heu.s3.amazonaws.com/wp-content/.../2011/.../Health-Managementreport_final.p (accessed 17 August 2017).

Accepted 11 January 2017.

Afr J Health Professions Educ 2017;9(3):92-93. DOI:10.7196/AJHPE.2017.v9i3.856

September 2017, Vol. 9, No. 3 AJHPE

Short Research Report

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

A quick needs assessment of key stakeholder groups on the role of family medicine in Zambia J Sanders,1 MD; M Makasa,2 MD; F Goma,3 PhD; E Kafumukache,4 MMedSci; M S Ngoma,5 MRCP; S Nzala,6 MD 1

Department of Family and Community Medicine, Faculty in the School of Medicine, Medical College of Wisconsin, Milwaukee, USA

Department of Community and Family Medicine, Faculty in the School of Public Health, University of Zambia, Lusaka

Centre for Primary Care Research, Faculty in the School of Medicine, University of Zambia, Lusaka

Department of Anatomy, Faculty in the School of Medicine, University of Zambia, Lusaka

Department of Paediatrics and Child Health, Faculty in the School of Medicine, University of Zambia, Lusaka

Department of Medical Education Development, Faculty in the School of Medicine, University of Zambia, Lusaka

Corresponding author: J Sanders (jsanders@mcw.edu)

Background. Zambia is a nation of nine million people, and has too few physicians to meet the country’s health needs. Following the strategy of other subSaharan countries, Zambia has developed a training programme in family medicine to help improve the medical competencies of its physician workforce. A needs assessment was undertaken to better understand the landscape into which Zambian family medicine is being placed. Methods. In 2014, a nine-question survey in Likert-scale format was developed, validated, and then delivered to four stakeholder groups: (i) practicing clinical physicians, (ii) the general public, (iii) the University of Zambia’s School of Medicine’s academic faculty and (iv) medical students. The needs assessment was delivered through several different mechanisms: via web-based service, to respondents’ email addresses; in paper form, to population samples of convenience; and verbally, through face-to-face encounters. Results. The number of stakeholders from each group who responded to the needs assessment were: clinical physicians, 27; general public, 15; academic faculty, 14; and medical students, 31. Five of the nine survey statements achieved super-majority consensus, with >66% of stakeholders in each group agreeing. Two additional statements achieved a simple-majority consensus with >50% agreement within each stakeholder group. Conclusion. This survey suggests that there is a broad-based a priori understanding of family medicine in Zambia, and general agreement that its presence would be valuable to Zambia’s healthcare system. Afr J Health Professions Educ 2017;9(3):94-97. DOI:10.7196/AJHPE.2017.v9i3.831

General practitioners (GPs) have long been important for the delivery of healthcare services in Zambia, and they currently represent the largest class of physicians in the country. However, as the health needs of the Zambian population have become more complex, the training of the GP has not been able to keep pace. As a result, Zambia’s healthcare workforce has been challenged to keep up with the country’s increasingly complex health service demands. Zambia is not alone in being confronted with a mismatch between the competencies of its healthcare workforce and the needs of the population. Many countries in the region face a similar set of issues, and have looked to family medicine as a strategy to improve their country’s health outcomes.[1,2] Family medicine is seen by the region’s healthcare planners and administrators as an attractive solution to addressing some of the region’s health needs, because it offers a broad scope of advanced medical competencies within the embodiment of a single practising physician. From the mid-1960s until 2012, Zambia only had one medical school, which was situated in the country’s capital, Lusaka. Initially, the educational focus was on training physicians to a GP’s level. Training to a more advanced clinical level, such as adult medicine, paediatrics, general surgery and obstetrics and gynaecology, did not begin until the 1990s. Other speciality postgraduate programmes have been recently introduced, and now include orthopaedics, ophthalmology, anaesthesiology, psychiatry and infectious diseases.

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Ironically, one of the consequences of training to a speciality level has been the diminished capacity of the Zambian health sector’s ability to consistently provide full-service care to its patients. This is because medical specialists tend to aggregate towards more tertiary healthcare settings, making them less accessible to the general population. It is also true that in Zambia it is rare to find enough specialists in any one location to meet the needs of the presenting patients.[3-5] This is especially so for the majority of Zambians, who live outside of large city centres.[6] In 2011, the University of Zambia’s School of Medicine committed itself to begin a postgraduate training programme in family medicine, with special focus on alleviating the shortage of specialist doctors at the district level. A 5-year grant from the US government, the Medical Education Partnership Initiative, supported this commitment. In a country with no tradition of family medicine as a medical speciality, it was not self-evident that a unipolar plan of action from the University of Zambia’s School of Medicine would be sufficient for success. Accordingly, we undertook a needs assessment of different stakeholder groups within the country’s healthcare landscape to better understand how family medicine might be received. A Medline search using the key words ‘survey’, ‘needs assessment’, ‘family medicine’ and ‘Africa’ yielded only one published report for comparison.[7,8] To our knowledge, however, our study is the first a priori needs assessment in sub-Saharan Africa to critically examine the receptivity

Short Research Report

Methods

In 2014, an anonymous nine-question survey was developed using a common five-point Likert scale for answers. Items were scored ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5) (Table 1). The survey was validated for content by having the six members of the University of Zambia’s School of Medicine’s Working Group on Family Medicine review each statement and answer the survey for themselves. Each of the workinggroup members critically appraised the survey’s statements for accuracy and validity. Additionally, representatives from each stakeholder group were approached in an ad hoc manner and were led through a facilitated process of progressive inquiry around each of the survey’s statements. The iterative process continued until each statement was refined and considered valid for all target stakeholder groups. Four key stakeholder groups were identified and targeted for solicitation about their participation in family medicine’s future: faculty at the medical school who would have the responsibility to teach this new kind of postgraduate learner; medical students who would need to be attracted to this area of medicine and see a professional future for themselves within it; practising physicians who would need to make room within their ranks for graduates of family medicine; and the public at large, who, by being the end consumer of family medicine, would need to ‘buy’ what family medicine was ‘selling’ if there was going to be longterm sustainability. Criteria for inclusion included being >18 years of age and able to speak English. Three out of the four stakeholder groups speak English as a matter of their daily professional lives, and it is also the most widely spoken second language in Zambia, with even higher prevalence in the larger cities. At the time of the survey distribution, English was the exclusive language of instruction for all Zambian public schools.[9] Respondents were drawn mostly from populations of convenience, such as the University of Zambia’s School of Medicine faculty, who had come together for the purpose of another meeting, or a group of medical students between lectures. The academic faculty and the medical students were given paper-based surveys to fill out. Clinical physicians were contacted via a web-based software platform that delivered the survey to the email addresses of the physician members of the Zambian Medical Association. Members of the general public were approached in public areas of Lusaka, and the survey was delivered to Table 1. The survey instrument Using a scale of 1 - 5, please respond to the following statements: 1 2 3 4 5 Strongly disagree Strongly agree I am familiar with family medicine as a medical speciality. I know a family physician who practises in Zambia. There is a need for training family physicians in Zambia. Family medicine is important to Zambia’s health. Family medicine is well understood as a speciality. Family medicine will be welcome within the Zambian medical profession. Family-medicine physicians can be leaders in clinical care. Family-medicine physicians are best suited for district healthcare. Family-medicine physicians are best suited for District Health Officer positions.

them by face-to-face interviews. The method of convenience sampling was chosen as a compromise to expedite this a priori study, because other higher-profile efforts to organise family medicine within the country were on the verge of being rolled out, and news of these efforts might have biased respondents. The same interviewer was used for all face-to-face interviews, so as to improve the reliability and accuracy of the reported results. The sample size was considered sufficient to detect differences among responses, with a total of at least 80 respondents. This research was approved for human research by the University of Zambia’s Research Ethics Committee (ref. no. FWA00000338/IR800001 131 of IORG0000774).

Results

The number of respondents from each subgroup was: clinical physicians, 27; general public, 15; academic faculty, 14; and medical students, 31. Response rates were not calculated. Average scores for each question from each stakeholder group were calculated (Fig. 1). Additionally, an inter-stakeholder group comparison was done on a question-by-question basis. Responses have beenPractitioners collapsed so 5 Average score per statement Average score per statement

to family medicine within major stakeholder groups before any educational efforts were begun.

4.5 4 3.5 3 5 2.5 4.5 2 4 1.5 3.5 1 3 2.5 2 1.5 1

Students Public Academics

Practitioners Students Public Academics 1

Statement no.

Fig. 1. Average numerical score for each statement by stakeholder grouping. 100 90 80

100 70 90 60 80 50 70 40 60 30 50 20 40 10 30

% of respondents neutral

% of respondents agreeing with statement

% of respondents disagreeing with statement

1 2 3 % of respondents neutral % of respondents neutral 20 5 8 % of respondents agreeing with statement % of respondents agreeing with statement 46 29 91 % of respondents disagreeing with statement % of respondents disagreeing with statement 34 66 1

9 4

% of respondents neutral

% of respondents agreeing with statement

% of respondents disagreeing with statement

Fig. 2. Family medicine in Zambia: aggregated results.

September 2017, Vol. 9, No. 3 AJHPE

Short Research Report that ‘disagree’ and ‘strongly disagree’ are coupled, as are ‘agree’ and ‘strongly agree’ (Fig. 2). There is wide-based concordance between the different stakeholder groups. More than 66% of each stakeholder population agreed that there is: • a lack of family medicine physicians currently in Zambia • the desire for Zambia to have a training programme for family medicine physicians • a recognition of the role that family medicine physicians can play in improving Zambia’s health landscape • a sense that family medicine will be welcome within the professional ranks of medical specialists • an acknowledgement of the central roles within the Zambian health system that family medicine physicians might inhabit. In addition, >50% of each stakeholder population agreed that: • family medicine physicians would be well-suited to care for patients at the district level of health services. • there is a need to educate the country at large about the speciality of family medicine.

Discussion

There was a broad-based consensus among the respondents from each of the four stakeholder groups, despite the disparity in their make-up. The respondents were made up of taxi drivers, bureaucrats, shopkeepers, students, restaurant patrons, academics, clinicians and a variety of others. All seemed to speak with one mind. For seven of the nine statements, more respondents answered in agreement with one another than in disagreement, and the two remaining statements that did not meet majority consensus failed to do so by less than 5% each. One possible explanation for this general agreement across most statements is the simple nature of some of them. For example, the statement ‘family medicine is important to Zambia’s health’ sounds very much like ‘rain is important for Zambia’s crops’: it is hard to disagree with a statement having such an obvious answer. Yet this idea belies the deeper complexities of the survey's other statements, which were also answered with a high degree of intergroup correlation. Statements 1, 2 and 5 all dealt with the respondents’ familiarity with family medicine. Fig. 1 shows that there was fairly high congruency across all four of the respondent groups on this topic. Fig. 1 also shows that across all respondent groups, there was a high degree of intergroup congruency on what they all thought about the development of family medicine in Zambia (questions 3, 4, and 6). It is interesting to note that despite a general unfamiliarity with the speciality, there is a general recognition that family medicine can play a central role in Zambia’s healthcare landscape. Furthermore, respondents also noted the speciality’s innate capacity to train physicians to become leaders within Zambia’s healthcare hierarchy. One possible explanation for the high intergroup congruency is that the idea of family medicine has already arrived in Zambia, even if its actual physical embodiment has yet to materialise. After all, at the end of the day, stakeholders from each group are, in some aspect, all consumers of the Zambian health system. The respondents might have intuitively recognised what other research has shown: a family-medicine physician

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represents a very efficient way to bring competent human resources to the clinical and managerial challenges facing stressed health systems. [10,11]

This survey and its results proved to be highly beneficial to the momentum of garnering stakeholder buy-in for family medicine’s continued development in Zambia. The details of the evolution of family medicine in Zambia, and the road ahead, are described elsewhere, and are outside of the scope of this article.[12,13] There are some structural limitations to our survey. Our survey was limited in that it only included speakers of English. The vast majority of Zambians speak a mother tongue other than English. As a result, there might have been some misunderstandings of the survey’s statements, despite our pre-testing validation, and the respondents might have been skewed towards those belonging to a more educated or merchant class. Additionally, the ‘general public’ group was drawn solely from the capital city of Lusaka. The rural inhabitants of Zambia, for whom family medicine is being expressly developed, were not consulted, and might have opinions significantly different from their urban-dwelling countrymen. Nonetheless, the survey’s findings are interesting and give us an indication of attitudes and knowledge about family medicine in Zambia. However, due to the limited sample size, these findings cannot be generalised.

Conclusion

Our survey demonstrated that the idea of family medicine was broadly recognised by the population sampled, and that there was wide-based receptivity to its local development. These findings could be used as a basis for developing family medicine programmes in Zambia. Further, other academic medical centres looking to begin family medicine might also use these results as a basis for their own stakeholder inquiries. Acknowledgements. None. Author contributions. JS was responsible for study design, oversight of study activity, data analysis and development of the manuscript. MM was responsible for data collection, data analysis and development of the manuscript. FG was responsible for the development of the manuscript. EK was responsible for study design and the development of the manuscript. SN was responsible for study design, human ethics committee application and development of the manuscript. MSN was responsible for the development of the manuscript. Funding. There was no external funding for this study. Conflicts of interest. None.

1. Flinkenflogel M, Essuman A, Chege P, Ayankogbe O, Maeseneer J. Family medicine training in subSaharan Africa: South-South cooperation in the Primafamed project as strategy for development. Fam Pract 2014;31(4):427-436. https://doi.org/10.1093/fampra/cmu014 2. Hellenberg D, Gibbs T. Developing family medicine in South Africa: A new and important step for medical education. Med Teach 2007;29(9-10):897-900. https://doi.org/10.1080/01421590701827890 3. Atkinson S, Ngwengwe A, Macwan’gi M, Ngulube T, Harpham T, O’Connell A. The referral process and urban healthcare in sub-Saharan Africa: The case of Lusaka, Zambia. Soc Sci Med 1999;49(1):27-38. https://doi. org/10.1016/s0277-9536(99)00072-6 4. Few R, Harpham T, Atkinson S. Urban primary healthcare in Africa: A comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam. Health Place 2003;9(1):45-53. https://doi.org/10.1016/s13538292(02)00029-1 5. Zulu J, Michelo C, Msoni C, Hurtig A, Byskov J, Blystad A. Increased fairness in priority setting processes within the health sector: The case of Kapiri-Mposhi District, Zambia. BMC Health Serv Res 2014;14:75. https://doi. org/10.1186/1472-6963-14-75 6. Ferrinho P, Siziya S, Goma F, Dussault G. The human resource for health situation in Zambia: Deficit and maldistribution. Hum Resour Health 2011;9:30. https://doi.org/10.1186/1478-4491-9-30

Short Research Report 7. Gossa W, Wondimagegn D, Mekonnen D, Eshetu W, Abebe Z, Fetters M. Key informants’ perspectives on development of family medicine training programs in Ethiopia. Adv Med Educ Pract 2016;7:261-269. https:// doi.org/10.2147/amep.s94522 8. Essuman A, Anthony-Krueger C, Ndanu TA. Perceptions of medical students about family medicine In Ghana. Ghana Med J 2013;47(4):178-184. 9. Lusaka Times. Use of local language as a medium of instruction to be implemented next year. 18 January 2013. https://www.lusakatimes.com/2013/01/18/use-of-local-languages-as-media-of-instruction-to-be-implementednext-year-for-pre-grade-4/ (accessed 2 August 2017). 10. Starfield B. Is primary care essential? Lancet 1994;344(8930):1129-1133. https://doi.org/10.1016/s01406736(94)90634-3

11. Starfield B, Leiyu S, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83(3):457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x 12. Makasa M, Nzala S, Sanders J. Developing family medicine in Zambia. Afr J Prm Health Care Fam Med 2015;7(1). https://doi.org/10.4102/phcfm.v7i1.909 13. Sanders J, Makasa M, Goma F, Kafumukache E, Ngoma M, Nzala S. Developing a family medicine post-graduate training program in Zambia. Fam Med 2016;48(7):517-522. https://doi.org/10.4102/phcfm.v7i1.909

Accepted 3 November 2016.

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Research

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

Registrar wellness in Botswana: Measuring burnout and identifying ways to improve wellness K D Westmoreland,1,2,3 MD; E D Lowenthal,1,3,4 MD, MSCE; R Finalle,1,4 MD; L Mazhani,2 MD; M Cox,5 MD; J C Mwita,6 MD; S B Mphele,7 PsyD; C E Turner,1 MD; A P Steenhoff,1,2,3,4 MB BCh, DCH 1

Global Health Center and Department of Pediatrics, The Children’s Hospital of Philadelphia, PA, USA

Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Botswana-University of Pennsylvania (Botswana-UPenn) Partnership, Gaborone, Botswana

University of Pennsylvania Perelman School of Medicine, PA, USA

Department of Emergency Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Department of Psychology, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Corresponding author: K D Westmoreland (katewestmoreland@gmail.com)

Background. Burnout during registrar training is high, especially in resource-limited settings where stressors are intensified. Burnout leads to decreased quality of life for doctors, poor job and patient satisfaction, and difficulty retaining doctors. Objectives. Primary: to measure burnout among registrars working at Princess Marina Hospital in Gaborone, Botswana. Secondary: to determine factors contributing to burnout and identify potential wellness interventions. Methods. The validated Maslach Burnout Inventory was used to measure the degree of emotional exhaustion, depersonalisation and personal accomplishment. Work-related difficulties and potential wellness interventions were explored through multiple-choice and open-ended questions. Results. Of 40 eligible registrars, 20 (50%) completed the survey. High levels of burnout were reported for emotional exhaustion in 65% (13/20), depersonalisation in 45% (9/20), and personal accomplishment in 35% (7/20) of registrars. A high degree of burnout was reported by 75% (15/20) of registrars in one or more domains. In the previous 7 days, registrars worked an average of 77 hours, took 1.5 overnight calls, slept 5.7 hours per night, and 53% (10/19) had ≥1 of their patients die. Five (25%) registrars considered leaving Botswana to work in another country, which correlated with those with the highest degree of burnout. The most common frustrations included insufficient salary and limited medical resources. Suggested interventions included improved mentorship and wellness lectures. Conclusions. There is a high degree of burnout, especially emotional exhaustion, among registrars. Encouragingly, most registrars have a desire to work in Botswana after training. Future research on improving registrar wellness in low-resource settings is urgently needed. Afr J Health Professions Educ 2017;9(3):98-102. DOI:10.7196/AJHPE.2017.v9i3.881

A registrar is a medical doctor undergoing training to become a specialist. Registrars frequently feel exhausted because of long working hours, overwhelmed by having a large body of clinical knowledge to master, stressed because of patients who depend on them for survival, financially burdened owing to an insufficient salary, and challenged with balancing the demands of professional and personal life.[1,2] Registrars often have tremendous responsibilities at work; yet, they have very little autonomy. According to the job demand-control-support model, employees who work in jobs with high demands, low control, and low social support experience the lowest level of psychological and physical wellbeing.[3] Therefore, registrars are at high risk of developing burnout.[4] Burnout has been defined as a three-dimensional syndrome that includes emotional exhaustion, depersonalisation and reduced personal accomplishment.[5] Emotional exhaustion is a depletion of emotional resources. Depersonalisation is a negative and cynical attitude towards others. Reduced personal accomplishment is a negative and dissatisfied evaluation of oneself. Unlike major depressive disorder, which affects all aspects of a person’s life, burnout is a distinct work-related syndrome.[5]

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Globally, research has shown that burnout rates among doctors range from 25% to 76%.[1,4,6] Burnout has been correlated with various physical symptoms, including fatigue, insomnia, headaches and gastrointestinal distress.[1,4,5] Potential consequences of burnout include an increase in alcohol and drug use, a higher rate of depression, and an increased incidence of marital and family problems.[1,4,5] Doctors who are burnt out are more likely to self-report suboptimal patient care and medical errors.[6,7] Burnout often decreases empathy, compassion, and availability of doctors for their patients, which leads to lower patient satisfaction.[8] Overall, burnout can negatively impact a registrar’s quality of life and the ability to provide sustainable, safe, and empathetic patient care, simultaneously weakening the morale of registrars in training programmes.[1,4,6,8] In resource-limited settings, work-related stresses are amplified compared with those of doctors working in resource-rich settings.[9,10] Registrars in resource-limited settings often work in overcrowded hospitals with inadequate medical supplies and equipment, have fewer mentoring and career-building opportunities, are paid less, and are faced with high patient mortality rates. In sub-Saharan Africa, HIV has added to the workload, with

Research a higher burden, acuity, and complexity of disease, and has increased the number of patient deaths.[10,11] These added stressors of doctors working in resource-limited settings may lead to higher rates of burnout.[9,10] There are only a few published reports on registrar burnout from subSaharan Africa, with the majority from South Africa (SA). One study of 22 junior doctors in Cape Town, SA, described that 100% experienced a high degree of burnout, and all but one expressed the intention to leave the public hospital where they were working after completing training.[10] A second study from SA found that 26% of registrars and medical officers working at a public healthcare facility experienced a high degree of burnout.[12] A third study in SA reported that 27% of anaesthesia registrars experienced a high degree of burnout, which was significantly higher when compared with the consultants.[13] Outside of SA, there was only a single study from Kenya describing that 82% of registrars self-reported being moderately affected by burnout, but this was not formally evaluated with a standardised burnout inventory.[11] Currently, there are no available data on burnout rates among doctors in Botswana, a setting with a new medical school, high population prevalence of HIV, and a number of new registrar training programmes. The primary objective of this study was to measure burnout among registrars working at Princess Marina Hospital (PMH) in Gaborone, Botswana. The secondary objectives were to determine possible factors associated with or protective against burnout and to identify possible wellness interventions that could be implemented in this resource-limited setting to prevent and minimise burnout.

Methods

Study setting

PMH is a 525-bed tertiary referral hospital in Gaborone. It is the largest hospital in Botswana and serves the southern half of the country, as well as selected referrals from the north. In 2009, the University of Botswana opened the country’s first medical school, and it remains the only medical school in the country. PMH is the academic teaching hospital and site for clinical rotations for medical students at the University of Botswana. The university has registrars in paediatrics, internal medicine, emergency medicine, family medicine, pathology and public health. The registrar training programme spans 4 years, with clinical rotations in both Botswana and SA. The 5th year is a chief resident or senior registrar year in Botswana, during which registrars complete both their Master in Medicine research thesis and, for those who have not yet done so, their respective South African Colleges of Medicine final specialist examinations.

Study design and instruments

All registrars in Botswana who provide direct patient care at PMH were invited to participate in this study, which used a two-part survey questionnaire. The first part of the questionnaire used the Maslach Burnout Inventory (MBI) for health service workers to measure the level of burnout experienced by the registrars. The MBI, first formulated in 1981, was designed for and validated in all categories of human service.[5] It consists of 22 items that measure emotional exhaustion, depersonalisation and diminished feelings of personal accomplishment through 7-point Likert scales, indicating the frequency of characteristic symptoms.[5] The MBI has established construct, and discriminant and convergent validity.[5] It is valid, reliable and consistent, having been used to study burnout across professions, countries, languages and cultures.[5] The MBI has been tested extensively and has become the gold standard for identifying burnout in the medical research literature.[4] It

has been validated and used across Africa to measure burnout in healthcare workers, including registrars, with most extensive use in SA.[10,12-14] The second part of the questionnaire included demographic information, work and wellness-related questions, questions to assess potential factors associated with and protective from burnout, and questions to assist in developing a future wellness programme. The questions were in multiplechoice and open-ended free-text format.

Enrolment of participants

The questionnaire was administered using Research Electronic Data Capture (REDCap) software (USA).[15] The questionnaire link was emailed to all University of Botswana registrars who were providing direct patient care at PMH: 20 paediatric, 16 internal medicine, and 4 emergency medicine registrars. Pathology and public health registrars were excluded, as they do not provide direct patient care. Family medicine registrars were also excluded, as they provide the majority of their clinical care outside of PMH in the district hospitals. Prior to initiation of the study, it was explained in person during academic meetings to all eligible registrars by the study’s principal investigator (KW). Further study information was provided electronically via email using REDCap, and informed consent was obtained. All responses were de-identified through REDCap to ensure respondent confidentiality. As recommended in the MBI manual, the questionnaire was presented as a survey on registrar wellness and job-related attitudes and did not mention burnout – to ensure that the respondents were not sensitised to the concept of burnout and did not tailor their responses in that regard.[5] We aimed for a response rate of at least 50%, allowing for a margin of error of ±15% around the 95% confidence level. Requests to complete the questionnaire were re-sent to qualifying registrars until a 50% response rate was reached.

Analysis

The MBI scores were calculated and classified based on the recommended normative values.[5] A high degree of burnout is reflected by high scores on emotional exhaustion and depersonalisation subscales and low scores on the personal accomplishment subscale, which is protective against burnout.[5] Each of the three dimensions of burnout is categorised as high, moderate, and low, using standardised numerical cut-off points provided by the MBI manual for medical providers (Table 1).[5] The scores are considered high if they are in the upper third of normative distribution, average if they are in the middle third, and low if they are in the lower third.[5] As set out in the manual, we described each of the three dimensions of burnout separately, and not as a single combined score.[5] The median and interquartile range (IQR) were provided for each dimension of burnout (emotional exhaustion, depersonalisation and personal accomplishment). Scores in our population were compared with those for the 1 104 normative medical professionals provided in the MBI manual for each dimension of burnout.[5] Normality of our samples was tested using the Shapiro-Wilk test, and then either one sample t-test or the Wilcoxon signed-rank test was used, as appropriate, based on the distribution of data. Table 1. Classification of the three dimensions of burnout for medical professionals as defined by the Maslach Burnout Inventory Dimensions of burnout

Low

Moderate

High

Emotional exhaustion

≤18

19 - 26

≥27

Depersonalisation

≤5

6-9

≥10

Personal accomplishment

≥40

39 - 34

≤33

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Research Demographic data and multiple-choice responses were described using median, IQR, ratio and percentages. The free-text answers were descriptively summarised.

Ethical approval

Each registrar programme director from paediatric, emergency and internal medicine individually approved this study. The study was reviewed and approved by the Institutional Review Boards of the Botswana Ministry of Health (ref. no. 13181), the University of Botswana (ref. no. 1475), and the University of Pennsylvania, USA (ref. no. 820222). The validated MBI instrument was purchased from Mind Garden, Inc. (USA)[5] and permission and a licence were obtained to use the questionnaires for this research project.

Results

Of 40 eligible registrars, 20 (50%) completed the survey: 11/20 (55%) paediatric registrars, 2/4 (50%) emergency medicine registrars, 6/16 (38%) internal medicine registrars and 1 unknown. Of the 20 respondents, 19 completed the entire survey, and 1 completed the MBI portion only, but not the demographic, work- and wellness-related questionnaire portion. The median age of the 19 respondents who completed the entire survey was 32 (IQR 31 - 34) years, with 11/19 (58%) male. Nine of 19 (47%) were married and 14/19 (74%) had children. Respondents had a median of 3 (IQR 2 - 4) years of postgraduate work experience prior to registrar training. In the previous 7 days, registrars worked an average of 77 (IQR 67 - 85) hours, took 1.5 (IQR 1 - 2) overnight calls, slept 5.7 (IQR 5 - 6) hours per day, and exercised 1.3 (IQR 0 - 2) hours per week. In 53% (10/19) of registrars, â&#x2030;Ľ1 of their patients died in the previous week.

Burnout

A high degree of burnout was reported by 75% (15/20) of registrars in â&#x2030;Ľ1 domains, 55% (11/20) in 2 - 3 domains, and 15% (3/20) in all 3 domains of burnout. Twenty-five percent (5/20) of registrars did not experience a high degree of burnout in any domain. Fig. 1 depicts the degree of burnout for each domain reported among registrars. Emotional exhaustion Burnout scores for emotional exhaustion were found to be high for 65% (13/20), moderate for 20% (4/20), and low for 15% (3/20) of respondents. Our PMH cohort had a median emotional exhaustion of 35.5 (IQR 23.5 - 41.0), 20 18 16

Registrars, n

65%

45%

30%

High

Moderate

Low

50%

4 2

35% 15%

0 Emotional exhaustion

Depersonalisation

Personal accomplishment

Burnout domains

Fig. 1. Burnout experienced by clinical registrars working at the Princess Marina Hospital in Gaborone, Botswana (n=20).

100

n (%)

Insufficient salary

17 (94)

Limited resources

16 (89)

Long working hours

13 (72)

Overnight calls

13 (72)

Insufficient support from ancillary staff

11 (61)

Work-life balance

9 (50)

Overwhelmed by too many patients

9 (50)

Insufficient support from administration

8 (44)

Insufficient support from consultants

6 (33)

Inadequate knowledge base

5 (28)

Medical complexity of patients

2 (11)

Difficulties coping emotionally with death of patients

2 (11)

Table 3. Stress reduction techniques practised by clinical registrars working at Princess Marina Hospital in Gaborone, Botswana (n=18) Stress reduction technique

n (%)

Spending time with family and friends

13 (72)

Alone time

11 (61)

Entertainment events

10 (56)

Exercise and sports

9 (50)

Sleeping

9 (50)

Church

9 (50)

Taking holiday

8 (44)

Shopping

6 (33)

Cooking

4 (22)

Listening to or playing music

3 (17)

Hobby

2 (11)

Going out partying

2 (11)

Being outdoors

2 (11)

Drinking alcohol

1 (6)

Using drugs

1 (6)

which was significantly higher than the normative sample (mean emotional exhaustion score of 22.19 (standard deviation (SD) 9.53), t-test p=0.0011). 5%

20%

Factor leading to burnout

35%

12 10

Table 2. Factors leading to burnout as identified by clinical registrars working at Princess Marina Hospital in Gaborone, Botswana (n=18)

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Depersonalisation Burnout scores for depersonalisation were found to be high for 45% (9/20), moderate for 5% (1/20), and low for 50% (10/20) of respondents. Our PMH cohort had a median depersonalisation score of 5.5 (2.0 - 14.5), which was not significantly different than the mean of the normative sample (mean depersonalisation score of 7.12 (SD 5.22), Wilcoxon signed-rank test p=0.60). Personal accomplishment Burnout scores for personal accomplishment were found to be high for 35% (7/20), moderate for 30% (6/20), and low for 35% (7/20) of respondents.

Research

Table 4 summarises wellness activities suggested by the registrars. The most frequently proposed included lectures (wellness, stress reduction, work-life balance and career development), improved mentorship and registrar social events. There was an emphasis on improving the overnight on-call experience, including improved support from consultants, protected time off post-call, access to a cafeteria at the hospital, an on-call room for sleeping, and an on-call break room with access to a refrigerator and microwave. Other items that the registrars requested included improved salary, especially when rotating in SA, team building for the department, and protected non-clinical time to work on their Master in Medicine research project.

in the public sector. The development and implementation of wellness programmes into registrar training are both essential and urgently needed.[8,16] The first step towards addressing this problem is to describe the magnitude of registrar burnout. We describe a high degree of burnout, with statistically significant high levels of emotional exhaustion among clinical registrars training at PMH in Gaborone. It is encouraging, however, that most of the registrars continue to have a positive sense of personal accomplishment and expressed a desire to work in Botswana after training. We found that 75% of registrars had a high level of burnout in at least one domain. These results are in the upper range of normal for registrars internationally, with reports of burnout ranging from 25% to 76%.[1,4,6] A rate of high emotional exhaustion (65%) was similar to that described in studies from SA, where the level was 46 - 90%.[10,12] Twenty-six percent of the registrars reported the intention to leave Botswana to work in another country. A similar publication from SA reported that 95% of junior doctors expressed an intention to leave the public hospital where they were training, but the study did not evaluate the doctorsâ&#x20AC;&#x2122; intention to leave the country.[10] In our study, the registrars with a high level of burnout in all three domains and those with the highest scores of emotional exhaustion were over-represented among those who expressed a desire to leave Botswana to practise medicine elsewhere. It is therefore essential to prioritise the introduction of wellness interventions to decrease burnout and emotional exhaustion, as this will likely promote retention of newly trained specialists. From 1990 to 2009, the Botswana Ministry of Education trained ~1 000 doctors in foreign medical schools, of whom only 10% have returned home to work in Botswana.[17] In 2009, the University of Botswana opened Botswanaâ&#x20AC;&#x2122;s first medical school and established registrar training programmes in an attempt to increase the number of doctors in Botswana and improve the overall healthcare system.[17] The majority of sub-Saharan African countries have a critical shortage of healthcare providers, despite their high burden of disease. As a response, sub-Saharan African governments, with the assistance of the Medical Education Partnership Initiative (MEPI), have opened new medical schools throughout the region.[17] As new medical schools open across Africa, it is essential to study and better understand burnout among registrars in resource-limited settings to improve patient care, job satisfaction and retention of doctors in their home country. We found that the most common factors leading to burnout were insufficient salary, limited resources, long working hours and overnight calls, which are similar to factors reported in other studies.[4,10,18,19] The most frequently proposed wellness interventions by the Botswanan registrars included wellness lectures, improved mentorship and registrar social events. These requests are in line with the views of global experts, who are focusing on improving wellness of registrars-in-training, where both individually focused and organisational strategies have been found to decrease burnout among physicians.[4,16,19,20] The results from this study have led to the initiation of wellness activities for registrars at the University of Botswana, including wellness lecture series, access to free individual psychotherapy through the Department of Psychology and registrar social activities, including an annual appreciation luncheon. These activities have been well received by the registrars, but a continued focus on improving the wellness of registrars working in Botswana and across sub-Saharan Africa is urgently needed.

Discussion

Study limitations

Table 4. Wellness interventions suggested by clinical registrars working at Princess Marina Hospital in Gaborone, Botswana (n=18) Suggested wellness intervention

n (%)

Lectures on wellness, stress reduction and work-life balance

9 (50)

Lectures on career development

8 (44)

Improved mentorship

8 (44)

Registrar social events

7 (39)

Annual registrar overnight retreat

6 (33)

Psychologist offering individual psychotherapy

5 (28)

Support group during lunch

4 (22)

Stress reduction during lunch

3 (17)

Lecture on coping with patient death

2 (11)

Our PMH cohort had a median personal accomplishment score of 36.0 (IQR 28.5 - 40.2), which was not significantly different than the mean of the normative sample (mean personal accomplishment score 36.53 (SD 7.34), Wilcoxon signed-rank test p=0.35).

Future plans and retention

After registrar training, 58% (11/19) planned to seek sub-specialty training. Twenty-six percent (5/19) intended to leave Botswana after training to work in another country as a doctor, and 5% (1/19) of participants intended to leave the field of medicine after training. Sixty-seven percent (4/6) of registrars with the most severe emotional exhaustion on the MBI indicated their intention to leave Botswana. All registrars (3/3) with high levels in all three domains of burnout on the MBI indicated their intention to leave Botswana.

Factors leading to burnout

Table 2 summarises the job-related frustrations and difficulties that led to burnout. The most common were insufficient salary, limited resources, long working hours, and overnight calls.

Stress reduction

Table 3 summarises the most common stress-relieving activities that registrars practised. The most common were spending time with family and friends, alone time, and entertainment events.

Wellness interventions

Decreasing registrar burnout and improving quality of life and wellness are key to improving patient care, job satisfaction and retaining doctors

The limitations of our study include a relatively small sample size and 50% response rate. Multiple attempts were made to encourage responses from

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Research all registrars. It is unclear whether those who did not complete the study suffer to a greater or lesser degree from burnout than those who completed the study. It is difficult to get overworked registrars to fill out surveys, and other regional studies from SA report only a slightly higher response rate of 60 - 68%.[10,12,13] The strengths of this study include the use of a validated survey to measure burnout. The questionnaire was delivered electronically and completed on a voluntary and private basis, thereby minimising response bias.[5] Most importantly, this is the first study of registrar wellness in Botswana. Future studies with a larger sample size and in more countries throughout sub-Saharan Africa are needed to better understand burnout among registrars in resource-limited settings. Additionally, further research will provide more insight into ways to prevent burnout, improve wellness and retain doctors in high-need, low-resource settings. Acknowledgements. The authors would like to thank all the registrars at the University of Botswana for their hard work, dedication to their patients, and commitment to serving those in need. We would especially like to thank the registrars who took the time to complete the survey for this project. We are grateful to the leadership of the University of Botswana, Princess Marina Hospital, Botswana Ministries of Health and Education, Children’s Hospital of Philadelphia, Botswana-University of Pennsylvania (Botswana-UPenn) Partnership, and Pincus Family Foundation (USA). Author contributions. KDW: led study conception and design, acquisition of data, analysis and interpretation of data, drafting of the manuscript, editing and revising of the manuscript, and final approval of the version to be published; EDL, APS: assisted with study conception and design, analysis and interpretation of data, editing and revising of the manuscript, and final approval of the version to be published; RF, LM, MC, JCM, SBM, CET: assisted with study conception and design, editing and revising of the manuscript, and final approval of the version to be published. Funding. Funding for this project was provided by the Pincus Family Foundation (USA). Conflicts of interest. None.

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1. Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: A literature review. J Grad Med Educ 2009;1(2):236-242. https://doi.org/10.4300/jgme-d-09-00054.1 2. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident physician burnout: Is there hope? Fam Med 2008;40(9):626-632. 3. Van der Doef M, Maes S. The job demand-control (-support) model and psychological well-being: A review of 20 years of empirical research. Work Stress 1999;13(2):87-114. https://doi.org/10.1080/026783799296084 4. Thomas NK. Resident burnout. JAMA 2004;292(23):2880-2889. https://doi.org/10.1001/jama.292.23.2880 5. Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press, 1996:1-72. 6. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136(5):358-367. https://doi.org/10.7326/0003-4819-136-5-20020305000008 7. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study. JAMA 2006;296(9):1071-1078. https://doi.org/10.1001/jama.296.9.1071 8. Lebensohn P, Dodds S, Benn R, et al. Resident wellness behaviors: Relationship to stress, depression, and burnout. Fam Med 2013;45(8):541-549. 9. Ashkar K, Romani M, Musharrafieh U, Chaaya M. Prevalence of burnout syndrome among medical residents: Experience of a developing country. Postgrad Med J 2010;86(1015):266-271. https://doi.org/10.1136/pgmj.2009.092106 10. Stodel JM, Stewart-Smith A. The influence of burnout on skills retention of junior doctors at Red Cross War Memorial Children's Hospital: A case study. S Afr Med J 2011;101(2):115-118. https://doi.org/10.7196/samj.4431 11. Raviola G, Machoki M, Mwaikambo E, Good MJ. HIV, disease plague, demoralization and ‘burnout’: Resident experience of the medical profession in Nairobi, Kenya. Cult Med Psychiatry 2002;26(1):55-86. https://doi. org/10.1023/A:1015289132151 12. Sirsawy U, Steinberg WJ, Raubenheimer JE. Levels of burnout among registrars and medical officers working at Bloemfontein public healthcare facilities in 2013. S Afr Fam Pract 2016;58(6):213-218. https://doi.org/10.1080/ 20786190.2016.1198088 13. Van der Walt N, Scribante J, Perrie H. Burnout among anaesthetists in South Africa. S Afr J Anaes Analg 2015;21(6):169-172. https://doi.org/10.1080/22201181.2015.1102798 14. Naude JLP, Rothmann S. The validation of the Maslach Burnout Inventory – human services survey for emergency medical technicians in Gauteng. S Afr J Indust Psychol 2004;30(3):21-28. https://doi.org/10.4102/sajip.v30i3.167 15. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Informatics 2009;42(2):377-381. https://doi.org/10.1016/j.jbi.2008.08.010 16. Eckleberry-Hunt J, van Dyke A, Lick D, Tucciarone J. Changing the conversation from burnout to wellness: Physician well-being in residency training programs. J Grad Med Educ 2009;1(2):225-230. https://doi.org/10.4300/ jgme-d-09-00026.1 17. Mokone GG, Kebaetse M, Wright J, et al. Establishing a new medical school: Botswana’s experience. Acad Med 2014;89(8 Suppl):S83-S87. https://doi.org/10.1097/acm.0000000000000329 18. Rossouw L, Seedat S, Emsley RA, Suliman S, Hagemeister D. The prevalence of burnout and depression in medical doctors working in the Cape Town Metropolitan Municipality community healthcare clinics and district hospitals of the Provincial Government of the Western Cape: A cross-sectional study. S Afr Fam Pract 2013;55(6):567-573. https://doi.org/10.1080/20786204.2013.10874418 19. McClafferty H, Brown OW. Physician health and wellness. Pediatrics 2014;134(4):830-835. https://doi.org/10.1542/ peds.2014-2278 20. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet 2016;388(10057):2272-2281. https://doi.org/10.1016/s0140-6736(16)31279-x

Accepted 10 April 2017.

Research

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

Assessment of the educational environment of physiotherapy students at the University of Rwanda using the Dundee Ready Educational Environment Measure (DREEM) G Urimubenshi, MScPT; J Songa, BScPT; F Kandekwe, BScPT Department of Physiotherapy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda Corresponding author: G Urimubenshi (ugerardus@gmail.com)

Background. Getting students’ feedback regarding their experience of their educational environment (EE) is important. Objectives. To explore how physiotherapy students at the University of Rwanda (UR) feel about their EE. Methods. A descriptive quantitative cross-sectional study design with a census sampling strategy involving all physiotherapy students at UR was used. The Dundee Ready Educational Environment Measure was administered to 77 physiotherapy students in March 2015, to collect data that were analysed using the Statistical Package for the Social Sciences version 20 (IBM Corp., USA). The frequency distribution, mean, standard deviation and percentages were calculated, and the χ2 test was performed to assess whether responses showed significant variance according to level of study and gender. The level of significance (p-value) was set at 0.05. Results. The overall mean score on the 50 items was 62.20%. Students’ perception of learning scored the highest, with 66.58%, followed by students’ perception of atmosphere with 65.08%, students’ perception of teachers with 61.11% and students’ academic self-perception with 57.78%. The domain of students’ social self-perception scored the least, with 56.50%. All the domains scored positively toward the EE. There was no significant difference between male and female students, or between first-, second-, third- and fourth-year students regarding their perceptions of the EE. Conclusion. The physiotherapy students perceived UR as providing a sound EE. However, the data showed that there is a need for improvement in all five subscales of the learning environment at UR. Similar studies from other academic programmes at UR and other academic institutions in Rwanda are encouraged. Afr J Health Professions Educ 2017;9(3):103-106. DOI:10.7196/AJHPE.2017.v9i3.828

An educational environment (EE) is made up of three major compo nents: the physical environment, the emotional climate and the intellectual climate.[1] The EE of professional health training is mainly determined by the interactions between different stakeholder groups and the organisational structures of the environment.[2] Ideally, the EE should foster intellectual activities and academic progression, while simultaneously encouraging friendliness, co-operation and support. It is important to get students’ feedback on how they experience their EE.[3] Different studies aiming to assess medical or health sciences students’ perceptions of their learning environment have been conducted in many developed and developing countries, such as the UK, Saudi Arabia, Canada, India and Malaysia.[4] There is only one programme of physiotherapy education in Rwanda. This programme is hosted by the University of Rwanda (UR), and began in December 1996 with the vision of becoming a centre of excellence in training physiotherapy professionals in Rwanda and the whole East African region. Despite anecdotal feedback through informal conversations between the students and their lecturers, however, the EE as perceived by the UR physiotherapy students has never been formally assessed. This study aimed to explore how physiotherapy students at UR feel about their EE, to identify domains of strength and weakness, and to suggest ways to improve the students’ experience.

Methods

Study design

A descriptive cross-sectional study design was used.

Materials and subjects

The Dundee Ready Education Environment Measure (DREEM) was developed by Roff et al.[5] as a generic instrument for measuring students’ perceptions of undergraduate health professions curricula. It was administered to collect this data and information on characteristics, including age, gender and year of study. The DREEM instrument consists of 50 statements, and gives a universal score of a maximum of 200. It is capable of measuring five separate elements directly relevant to the educational environment: students’ perception of learning (SPOL), students’ perception of teachers (SPOT), students’ academic self-perceptions (SASP), students’ perception of atmosphere (SPOA) and students’ social self-perceptions (SSSP).[5] The DREEM questionnaire has been successfully tested for its internal validity and reliability.[6] The study population consisted of all 82 registered physiotherapy students at the College of Medicine and Health Sciences (CMHS) for the academic year 2014 - 2015. A census sampling strategy was used, but four students who assisted in data collection were excluded, and one student was not available during the data-collection period. Therefore, the study sample consisted of 77 participants.

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Research Data collection procedure

The DREEM questionnaire was administered to physiotherapy students at UR in March 2015, and scored according to standard guidelines.[7] The DREEM questionnaire consists of five-point Likert-scale responses to statements, as follows: strongly agree (4), agree (3), neutral (2), disagree (1) and strongly disagree (0). The score is reversed for negatively oriented statements. Items with a mean score greater than 3 represent strong areas; items with a mean score of less than 2 indicate problematic areas; and items with mean scores between 2 and 3 indicate areas that could be improved.

Data analysis

The Statistical Package for the Social Sciences (IBM Corp., USA) version 20 was used to analyse the data. The frequency distribution, mean and standard deviation (SD) were calculated, and the χ2 test was performed to assess whether responses showed significant variance according to level of study and gender (p=0.05). The mean score of each domain and the overall mean were calculated, and interpreted using the methods of Roff[7] as follows: 0 - 50 (0 - 25%) = very poor environment; 51 - 100 (26 - 50%) = multiple problems in the environment; 101 - 150 (51 - 75%) = more positive than negative environment; and 151 - 200 (76 - 100%) = excellent environment.

Ethics approval

Ethical clearance and permission to conduct the study were respectively granted by the CMHS Institutional Review Board (ref. no. CMHS/ IRB/010/2015) and the principal of CMHS (ref. no. 641/UR-CMHS/15). The students were formally briefed about the study and the questionnaire in their classrooms, and were informed that participation was voluntary and that they had the right to withdraw from the study at any time. In addition to this, the questionnaire was anonymous. All the students who were contacted consented to take part in the study, and they were requested to provide their demographic details and to respond to each of the 50 statements.

Results

Characteristics of participants

Questionnaires were administered to 77 physiotherapy students, and all returned the questionnaires completed, corresponding to a response rate of 100%. Table 1 reflects the distribution of the students across the 4 years of training. Table 2 describes the overall DREEM score and mean score for each domain. The total mean scores across the five domains vary between 56.50% (SSSP) and 66.58% (SPOL). The overall score is 124.4/200 (62.20%) Table 1. Distribution of respondents by gender and level of study (N=77) Variable

n (%)

Gender Male

53 (68.83)

Female

24 (31.17)

Level Year 1

14 (18.18)

Year 2

18 (23.38)

Year 3

21 (27.27)

Year 4

24 (31.17)

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Table 2. DREEM mean score for all study participants (N=77) DREEM domain

Maximum score

Mean (%) SD

Students’ perceptions of learning (SPOL)

31.96 (66.58) 0.30

Students’ perceptions of teachers (SPOT )

26.89 (61.11) 1.42

Students’ academic self-perceptions (SASP)

18.49 (57.78) 0.36

Students’ perceptions of atmosphere (SPOA)

31.24 (65.08) 0.72

Students’ social self-perceptions (SSSP)

15.82 (56.50) 0.16

Overall DREEM score

200

124.4 (62.20) 4.40

DREEM = Dundee Ready Educational Environment Measure.

(SD 4.40), meaning that the participants perceive their EE more positively than negatively. The study also aimed to test if the responses varied according to the level of study or the gender of the participants. As shown by Tables 3 and 4 below, no association was found (p>0.05).

Discussion

To the best of our knowledge, this is the first study providing information on the perceptions of physiotherapy students at UR of their EE. This study used a standardised questionnaire and a census sampling method. The results reflect the EE as experienced by physiotherapy students at UR, and may help different policy makers and physiotherapy lecturers at UR to generate responses for improvement. With an overall DREEM score of 124.4/200 (62.2%), the students rated the EE at UR as ‘more positive than negative’. This study also indicated that the students perceived each of the five EE domains more positively than negatively. It is not appropriate to fully compare this study with others, because of contextual dissimilarities and different sample sizes used. However, while contrasting and interpreting the scores against the guidelines proposed by the developers of the DREEM instrument, it emerged that this study has a common main finding with other similar studies conducted elsewhere, such as in India,[8] Malaysia,[9] Nigeria[10] and Sweden,[2] for example. All these studies reported that students view their EE in general as more positive than negative, thereby having an optimistic view of their learning situation, lecturers, educational atmosphere and academic and social life. The overall score (124.4/200) for the current study setting, which uses a student-centred learning approach, was higher than those found in Saudi Arabia (89/200),[11] Canada (97/200),[12] Bangladesh (110/200),[13] India (117/200)[8] and Malaysia (118/200).[14] It has been observed that students involved with innovative curricula (innovative in terms of providing a student-centred approach to education) tend to show more satisfaction with their learning environments, compared with students experiencing traditional curricula.[15] It is likely that the institutions that were studied in these countries offer conventional learning approaches. For instance, in one of the institutions, the College of Medicine at King Saud University, Saudi Arabia, the curriculum was reported as overcrowded and teacher centred.[11]

Research Table 3. Perception differences on EE in DREEM mean scores across years of study (N=77) Domains

Year 1 Mean (%) SD

Year 2 Mean (%) SD

Year 3 Mean (%) SD

Year 4 Mean (%) SD

p-value

SPOL

32.08 (66.83) 3.61

32.02 (66.71) 4.156

31.62 (65.88) 3.89

31.47 (65.56) 3.87

0.970

SPOT

25.95 (58.98) 3.121

25.57 (58.11) 3.44

27.34 (62.14) 2.86

28.68 (65.18) 3.00

0.912

SASP

18.72 (58.50) 2.68

18.84 (58.88) 2.80

18.06 (56.44) 2.74

18.35 (57.34) 2.78

0.486

SPOA

30.59 (63.73) 3.80

30.67 (63.90) 4.95

31.73 (66.10) 4.37

31.98 (66.63) 4.40

0.47

SSSP

15.97 (54.04) 2.57

15.75 (56.25) 2.85

15.63 (55.82) 3.06

15.94 (56.93) 3.12

0.73

p≤0.05 is considered significant. DREEM = Dundee Ready Educational Environment Measure; EE = educational environment; SPOL = students’ perceptions of learning; SPOT = students’ perceptions of teachers; SASP = students’ academic selfperceptions; SPOA = students’ perceptions of atmosphere; SSSP = students’ social self-perceptions.

However, the score found in the current study was lower than those found in Nigeria (131/200),[10] Malaysia (133/200),[9] Sri Lanka (141/200)[16] and Sweden (150/200).[2] This may reflect that these institutions are fairly innovative in terms of providing a student-centred approach to education,[17] and the physiotherapy lecturers at UR should explore how they can learn from good practices in those countries. The highest score in this study was found in the domain of SPOL. Several factors could have contributed to this SPOL score. The physiotherapy curriculum in Rwanda adheres to the standards of the World Confederation of Physical Therapy, the Rwanda Allied Health Professions Council and the Higher Education Council of Rwanda. In addition, physiotherapy education in Rwanda emphasises a competence-based and student-centred learning approach. The lowest mean score was found in the domain of SSSP. This finding is not surprising, as the majority of the physiotherapy students at UR do not have university accommodation, and live off-campus. This is a call to the UR administration to look for ways that the social welfare of the students can be improved. In contrast with some others,[8,18] this study revealed that there are no differences in the perceptions of EE between male and female students, or between first-, second-, third- and fourth-year students. Not having perception differences among the groups of students may indicate that the EE at UR is equally friendly to all students, and this may be a positive aspect of physiotherapy education in Rwanda.

Study limitations

The study has some limitations. The quantitative descriptive study design that was used does not provide participants with opportunities to tell their stories outside the boundaries of structured measurement scales, and therefore to bring depth and clarity to the understanding of experiences of EE. A mixed-method design would be better for such studies to evaluate EE.

Conclusion

The results of this study provide valuable clues as to how undergraduate physiotherapy students perceive their EE. Students were positive about teaching, their lecturers and educational atmosphere and their academic success, and had a good overall feeling regarding their social situation. Overall, students perceived that the institution provided a sound EE. However, the overall score of 62.20% indicates that there is a need for improvement of the learning environment of physiotherapy education at UR. Similar studies from other academic programmes at UR and other academic institutions in Rwanda using mixed-method designs are encouraged.

Table 4. Perception differences on EE in DREEM mean scores according to gender (N=77) Domains

Males mean (%) SD

Females mean (%) SD

p-value

SPOL

30.72 (64.00) 3.35

33.20 (69.17) 3.18

0.83

SPOT

26.34 (59.86) 3.71

27.44 (62.36) 4.22

0.25

SASP

19.01 (59.41) 4.30

17.97 (56.16) 4.12

0.88

SPOA

30.78 (64.13) 3.64

31.70 (66.04) 2.93

0.73

SSSP

15.72 (56.14) 3.35

15.92 (56.86) 3.44

0.16

p≤0.05 is considered significant. DREEM = Dundee Ready Educational Environment Measure; EE = educational environment; SPOL = students’ perceptions of learning; SPOT = students’ perceptions of teachers; SASP = students’ academic self-perceptions; SPOA = students’ perceptions of atmosphere; SSSP = students’ social self-perceptions.

Acknowledgements. The authors wish to express their gratitude to all physiotherapy students at UR who devoted their time to participate in the study. Author contributions. All authors conceived the study, analysed data, reviewed the manuscript and approved the final version of the manuscript. JS and FK collected data, and GU wrote the first draft of the manuscript and edited the final version. Funding. None Conflicts of interest. The authors declare that they have no conflict of interest.

1. Clapham M, Wall D, Batchelor A. Educational environment in intensive care medicine - use of Postgraduate Hospital EE Measure (PHEEM). Med Teach 2007;29(6):184-191. https://doi.org/10.1080/01421590701288580 2. Palmgren PJ, Lindquist I, Sundberg T, Nilsson GH, Laksov KB. Exploring perceptions of the educational environment among undergraduate physiotherapy students. Int J Med Educ 2014;5:135-146. https://doi. org/10.5116/ijme.53a5.7457 3. Abraham R, Ramnarayan K, Vinod P, Torke S. Students’ perceptions of learning environment in Indian medical school. BMC Med Educ 2008;8(3):20-24. https://doi.org/10.1186/1472-6920-8-20 4. Al-Rukban MO, Khalil MS, Al-Zalabani A. Learning environment in medical schools adopting different educational strategies. Educ Res Rev 2010;5(3):126-129. 5. Roff S, Mcaleer S, Harden RM, et al. Development and validation of the Dundee Ready Education Environment Measure (DREEM). Med Teach 1997;19(4):295-299. https://doi.org/10.3109/01421599709034208 6. Koohpayehzadeh J, Hashemi A, Soltani Arabshahi K, et al. Assessing validity and reliability of Dundee Ready Educational Environment Measure (DREEM) in Iran. Med J Islam Repub Iran 2014;28:60-68. 7. Roff S. The Dundee Ready Educational Environment Measure (DREEM), a generic instrument for measuring students' perceptions of undergraduate health professions curricula. Med Teach 2005;27(4):322-325. https://doi. org/10.1080/01421590500151054 8. Sunkad AM, Javali S, Shivapur Y, Wantamutte A. Health sciences students’ perception of the educational environment of KLE University, India as measured with the Dundee Ready Educational Environment Measure (DREEM). J Educ Eval Health Prof 2015;12:37-40. https://doi.org/10.3352/jeehp.2015.12.37 9. Veasuvalingam B, Arzuman H. Physiotherapy students’ perception of their educational environment: A study to identify the areas of concern for remedial measures at two schools of physiotherapy in Malaysia. Educ in Med J 2014;6(3):30-39. https://doi.org/10.5959/eimj.v6i3.233 10. Odole AC, Oyewole OO, Ogunmola OT. Nigerian physiotherapy clinical students’ perception of their learning environment measured by the Dundee Ready Education Environment Measure Inventory. Int J High Ed 2014;3(2):83-91. https://doi.org/10.5430/ijhe.v3n2p83 11. Al-Ayed IH, Sheikh SA. Assessment of educational environment at the College of Medicine of King Saud University, Riyadh. East Mediterr Health J 2008;14(4):953-959. 12. Audinet K, Davy J, Barkham M. University quality of life and learning (UNIQoLL): An approach to student wellbeing, satisfaction and institutional change. J Further High Educ 2003;27(4):365-382. https://doi. org/10.1080/0309877032000128073

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Research 13. Nahar N, Talukder HK, Khan TH, Mohammad S, Nargis T. Studentsâ&#x20AC;&#x2122; perception of educational environment of medical colleges in Bangladesh. BSMMU J 2010;3(2):97-102. https://doi.org/10.3329/bsmmuj.v3i2.7060 14. Arzuman H, Yusoff MSB, Chit SP. . Big Sib students' perceptions of the educational environment at the School of Medical Sciences, Universiti Sains Malaysia, using Dundee Ready Educational Environment Measure (DREEM) Inventory. Malays J Med Sci 2010;17(3):40-47. 15. Said NM, Rogayah J, Hafizah A. A study of learning environments in the Kulliyyah (Faculty) of Nursing, International Islamic University Malaysia. Malays J Med Sci 2009;16(4):15-24. 16. Perera D. The assessment of undergraduate physiotherapy education in Sri Lanka. Int J Sci Res Pub 2016;6(4):329-332.

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17. Brown T, Williams B, Lynch M. The Australian DREEM: Evaluating student perceptions of academic learning environments within eight health science courses. Int J Med Educ 2011;2(2):94-101. https://doi.org/10.5116/ ijme.4e66.1b37 18. Al-Naggar RA, Abdulghani M, Osman MT, et al. The Malaysia DREEM: Perceptions of medical students about the learning environment in a medical school in Malaysia. Adv Med Educ Pract 2014;5:177-184.

Accepted 14 December 2016.

Research

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

Standardised patient-simulated practice learning: A rich pedagogical environment for psychiatric nursing education A Jacobs, MSocSc Nursing; I Venter, PhD (Nursing) School of Nursing, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: A Jacobs (jacobsac@ufs.ac.za)

Background. Nursing education needs to adapt to be relevant to student nurses’ learning needs. This study investigates the use of standardised patients (SPs) in a simulated patient interview as a learning strategy to bridge the theory-practice gap. Simulation helps students to develop skills such as communication, higher cognitive thinking, decision-making and problem-solving. There is evidence to support the use of SP case scenarios to enable students to develop their clinical and interpersonal skills in a controlled environment before encountering patients in a clinical setting. Objective. To explore and describe students’ experiences of the developed SP scenario for the mental health nursing interview. Methods. A qualitative approach was taken and data were gathered using structured open-ended questions to gather information from 33 under graduate nursing students after they encountered the SP simulation. Participants’ responses were thematically analysed. Results. Nursing students experienced the simulation as challenging, but felt that being able to practise their skills within a safe simulated environment built confidence. They indicated that the experience was not only enjoyable, but that it helped them to integrate theory with practice, develop communication skills and feel professional. Conclusion. SP-simulated practice combined with classroom teaching is important in improving nurses’ professed ability to respond to patients’ needs. Nursing students need to be interpersonally competent before engaging with mental health users. SP-simulated learning helps student nurses to participate actively in a positive learning process; they then begin to understand the need for linking theory with practice. Afr J Health Professions Educ 2017;9(3):107-110. DOI:10.7196/AJHPE.2017.v9i3.806

Quality nursing education must go beyond the imparting of information. Teaching strategies must link theory to practice, foster critical thinking, be relevant and stimulate students. The strength of a pedagogical approach is the intentional integration of knowledge, clinical reasoning, skills practice and ethical comportment across the nursing curriculum.[1] When students implement their skills and knowledge, they become aware of the professional role their career entails. Professional nursing, through the action of its members, demonstrates accountability and responsibility towards society.[2] Psychiatric nursing practice is a complex interpersonal process that requires a professional nurse to be interpersonally competent. This competence needs to be incorporated into a systematic process of care, which demands not only integration of theory and practice, but also an in-depth understanding of the complexity of human interaction. Therefore, it is important to thoroughly prepare psychiatric nursing students before their first encounter with a real patient. Nursing simulations using standardised patients (SPs) have proven effective in creating realistic learning opportunities to enhance the students’ competencies necessary for mental health clinical practice.[3] Increasingly, simulation is being seen as a way to support the transfer of theory to practice and there is evidence that simulated contextual practice can prepare professionals for safe practice. Furthermore, evidence suggests that exposure to simulation decreases anxiety towards clinical practice among student nurses.[4] The process of simulated practice learning can help students to develop confidence, professional aptitude and competence before they deliver nursing care to a real patient.[5] Psychiatric nursing is often not the ultimate goal of students when enrolling in a nursing course and they may experience more anxiety due to their unfamiliarity with the

psychiatric setting.[6] SP simulation can assist these students by decreasing their anxiety and increasing their confidence. An SP is a person who acts as a patient in a standardised manner. Not only do SPs present the specified healthcare scenario, they also give constructive feedback to the students. SPs can teach student nurses to take a patient history, perform a mental status examination, practise psychiatric interventions and develop communication skills.[7] Several challenges in psychiatric nursing education can be addressed with SP simulation. One can ensure that all students are exposed to the same clinical situation or experience, and a specific situation or diagnosis is available on demand without having to wait for it. Students receive realistic feedback from a simulated patient in an honest and objective way, which is not easily available in the clinical practice situation.[8] Simulation as a learning strategy is new to South African (SA) nursing education, and therefore scenarios need to be developed to be aligned with learning needs. Research in the use of SPs in undergraduate nursing in SA, especially in psychiatric nursing, is sparse, but evidence suggests that it is an effective learning strategy.[9] The question is whether the scenarios for psychiatric nursing that we develop address the student nurses’ learning needs.

Objective

It was deemed necessary to investigate the undergraduate student nurses’ learning experiences after SP simulation. The purpose of this study was to explore and describe undergraduate nursing students’ experiences of conducting a psychiatric assessment on an SP presenting with a mental health problem.

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Research Methods

This is a qualitative descriptive study that explored nursing students’ experiences. An open-ended questionnaire consisting of five questions aimed to explore student nurses’ learning experiences. An explorative interview that acted as a pilot study was conducted with students who had participated in an SP simulation earlier in the year. This was to ensure that the questions were formulated in a manner that was clear and would elicit the appropriate responses. The questions were refined after the interview.

Population and sampling

The study population comprised 34 fourth-year student nurses registered in the baccalaureate nursing programme. A purposive sampling technique was used and 33 student nurses, who signed informed consent forms, comprised the unit of analysis. The inclusion criteria were registration in the psychiatric nursing module and having participated in the SP simulation.

SP-simulated learning process

As soon as possible after the procedure of conducting a psychiatric assessment had been taught, the students were exposed to an SP learning experience related to the theory. The simulation laboratory has individual interview rooms, allowing for 7 students to be accommodated simultaneously. On arrival, small groups of 7 students were briefed on the scenario and the outcomes, after which they participated in the SP simulation. Directly after the conclusion of the simulation, students were given feedback by the SPs on how they experienced the nursing care (from a patient’s point of view), which was followed by a debriefing session led by an experienced facilitator. The debriefing questions were based on Pendleton’s method, which assists the students as a peer group to reflect on their own learning while exploring the link between theory and practice.[10] For simulation to be effective, its authenticity must reflect the clinical situation as well as possible.[11] We use senior drama students of the Department of Drama and Fine Arts, who have been briefed on and trained in the scenario. In the case reported here the nursing students had to assess SPs who portrayed a student suffering from depression. They were given the following written instructions and objectives that had to be achieved: Do a psychiatric assessment of a mental healthcare user in this clinic by means of: • an interview (structured and unstructured) • observation • demonstrating interpersonal skills to lay the foundation of a relationship of trust • completing the psychiatric assessment form (included). After receiving the instructions and having had an opportunity to ask for clarification, the students interviewed the SPs.

Data collection

Directly after the debriefing session the students were asked to complete the following open-ended questionnaire: • How did you emotionally (personal and professional) experience the participation in the SP scenario? • What in the scenario did you experience as most valuable and what can you do differently next time? Please motivate your answer.

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• How did the SP experience help you in closing the gap between theory and practice and in which area in this learning experience did you benefit most? Please explain your answer. • How will this SP experience help you in the working environment? Please explain your answer. • What suggestions can you make in order for us to give you a better learning experience?

Data analysis

As this was a qualitative study, the authors adhered to the acknowledged inductive data analysis as described by Creswell,[12] according to the following steps: examining the patterns of meaning; categories and themes; and working back and forth between the themes and the data.

Trustworthiness

Trustworthiness is addressed by adhering to the principles of credibility, dependability, confirmability and transferability, according to Creswell.[12] By describing the stated parameters, using purposive sampling and an explorative interview, credibility was enhanced. Triangulation of data from all the groups increased the confirmability of the results, and an independent co-coder corroborated the trustworthiness of the study. Finally, a literature search was conducted as a basis for comparing, contrasting and contextualising the findings of the data.

Ethical principles

The researchers adhered to the ethical principles of beneficence, respect for human dignity and justice. The participants were informed about the study and asked to sign a document indicating that they participated voluntarily and that they had been informed about the nature of the research.[12] The questionnaire was completed anonymously. The necessary institutional permission (ref. no. ECUFS NR 34/2011) was obtained to conduct this research.

Results and discussion

Six themes emerged from the participants’ responses, i.e. positive learning experience, realistic and safe environment, integrating theory with practice, professionalism, confidence and processing skills in communication.

Theme 1: Positive learning experience

Many of the participants stated that they remembered more from a simulation session than from a lecture. In the process they found learning to be enjoyable, exciting and motivating. The following responses are evidence of this: ‘Best way of education.’ ‘I learned more in this situation than just sitting in a class listening to people talking about the work.’ ‘Learned more in one hour in the lab than three hours of lecture, because you’re having fun.’ ‘I really enjoyed it, I felt emotionally calm and content; a little bit of stress but it went away quickly.’ ‘It was great and motivating.’ A recurring theme was that the participants wanted more time in the simulation suite because it was challenging and pleasant: ‘It was challenging but joyful. It was good to have practical experience.’ ‘Very exciting to be in a new situation not knowing what to do or what to expect.’

Research ‘Wonderful experience. Allow us to evaluate our competence.’ ‘The experience was really exciting and good. It really made me put myself in the situation and it also helped trigger my mind.’

‘ With the theory you learn more of what may be but with the practical part you get to bring what theory taught you and do it practically.’ The participants found they could link theory and practice.

Shawler[13] describes SP simulation as a creative teaching strategy for psychiatric nursing and proclaims simulation use as important to ensure competency and quality nursing education. Functioning at a high cognitive level is required from students, as they learn to elicit information from patients with mental disorders in a controlled, realistic and safe environment.

Theme 2: Realistic and safe environment

To comply with the requirements of an SP learning experience it is important to create a realistic but safe environment. Campbell and Daley[14] describe three levels of enacting a reality-based simulation. First, the simulation must seem credible to the students. They need to feel the responsibility of a nurse providing nursing care to the patient and acknowledge their actions in this regard. Second, the simulation must address the teaching outcomes of the module; and third, the simulation must help the student nurse to retrieve the theory and to integrate it into practice. The participants commented on the realism of the situation and also stated that they felt free to develop their skills: ‘The fact that the patient was real. I got a chance to like really put my skills into practice, my communication skills and I also liked the environmental setting. It really ensured privacy and it instilled confidence in me.’ ‘The experience was realistic enough to implement all the aspects of theory. Very good!!’ The feedback from the ‘patient’ (SP) had a definite impact on the students’ learning. The students learned how the SPs experienced the encounter from a patient’s point of view and the SP made suggestions to help the student to be more competent in the future: ‘The chance to be me in the scenario and to deal with the patient in the same way as I would in practice and the honest feedback given after the session.’ Obtaining insight into how one is perceived by the patient is invaluable. Patients often do not know what the correct actions are – they only know how they experience the nurse. This kind of feedback is special because it rarely occurs in clinical practice. It is awkward to ask for this kind of feedback, as patients might not be able to or be too intimidated to convey their perceptions clearly and openly. SP feedback is a powerful teaching strategy to change students’ behaviour.[15]

Theme 3: Integrating theory with practice

Through integration of theory and practice, student nurses’ skills in health promotion, counselling, empathetic communication, and health screening improve, and they will adhere to practice guidelines.[13] The theory made more sense when they could apply their knowledge in a practical session. It is a way of cementing the theory and ingraining the knowledge and skills. The essentiality of a thorough theoretical grounding for skills is instilled in the students’ understanding and approach to practice: ‘Making the knowledge and skill your own.’ ‘It was of great value. It lets you think out of the box and generate your own way of approaching a patient and what you want to achieve.’ ‘It really helped me link what I learned during the week in class into practice now (today).’

Theme 4: Professionalism

McCormack and McCance[1] describe a professionally competent person as one who has skills that reflect a holistic approach, demonstrating knowledge and attitudes in a person-centred manner. One of the principles of practice in simulation is to encourage professional behaviour.[9] The SP learning situation gave the participants the opportunity to build a therapeutic relationship with the patient – experiencing themselves as professional nurses. The following responses indicated that the participants had started the process of building a therapeutic relationship with the patient, managing the patient’s emotions as well as their own: ‘Fact that the patient acted the scenario out, really is valuable because you feel you are with a real patient, which then automatically changes your perception with [sic] the whole scenario. You then start being serious and do your optimum best in bringing out the professionalism in you.’ ‘In the practical part I gained a lot and in learning the standards of professionalism.’ ‘It was really nice because the patient (actor) really looked real. That showed me the manner of professionalism I should have.’ Many participants commented on nursing being a hands-on profession, with one respondent suggesting: ‘I know I will not forget now as practice makes perfect.’ Milisen et al.[16] indicate that a person’s self-image and self-respect influence his or her professional aptitude. Student nurses will move towards independence and then gain experience, confidence and autonomy.

Theme 5: Confidence

As stated above, confidence is very important for the development of skills, and the SP experience gave the students just that: ‘It showed me where I should do more reading and practice. But gave me confidence to do it.’ ‘The feedback from the patient gave me confidence in doing the same in practice and to correct my mistakes.’ ‘It helped me build more confidence practising what I have learned in almost a real situation.’ ‘I felt more comfortable in doing this and the teaching method is more relevant to the subject, it also brings confidence.’ ‘I learn self-confidence, interpersonal skills, and patient-interaction skills.’ Students who were exposed to a simulation learning approach found that their learning needs were met and they experienced increased confidence; in the process the safe practices of individuals were improved. Confidence is closely linked to independence and the motivation to learn. SP-simulated learning ensures an interactive, safe and productive learning environment that fosters student nurses’ security and confidence.[14]

Theme 6: Processing skills in communication

Student nurses need to practise their verbal communication in a nurse-patient relationship for them to grow and develop from novice to expert. They need to be aware of how their own behaviour affects the patient and that

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Research communication is essential to understand the patients’ needs with regard to providing effective nursing care.[2] The importance of communication skills in nursing, and especially in psychiatric nursing, is critical. The participants reflected on their own skills and limitations, gaining an understanding of their abilities. In the process they discovered the value of empathy and listening skills: ‘Being an active listener is very important. Even hearing what is not being said.’ ‘Next time I will try to not repeat questions and give more attention or active listening to my patient in order to create trust between us.’ ‘Active listening to the patient such that I got absorbed in her story and went beneath just her answers but what she was communicating to me as well on a deep personal level.’ The value of therapeutic communication is a key component in a therapeutic relationship. Shawler[13] advises students to examine their own verbal and non-verbal communication.

Conclusion

Nursing educators need to be aware of their students’ learning needs and that the use of different learning strategies will help the students to gain knowledge and master skills. The integration of nursing theory with practice is crucial for becoming independent, autonomous registered nurses. SP-simulated learning helps student nurses to participate actively in a positive learning process and to understand the need for linking theory with practice. Nursing students need to be well grounded in therapeutic communication before engaging with mental health users. By providing a realistic, true-to-life experience for the development of competence in clinical skills, students are assisted to understand how they need to function in clinical practice. This allows them to acquire and process skills in communication and gain confidence in a safe environment in which they can learn by making mistakes, thus enhancing patient safety. The learning experience should include opportunities to question personal frames of reference that could hinder therapeutic engagement. Considering the limited research on the use of SPs in mental health nursing, especially in Africa, it was important to know whether the scenario resulted in effective learning. We can be cautiously confident that the scenario rendered a useful learning experience, as the students clearly stated that they found the experience very useful to master the skills necessary for a clinical situation. Further research should be done on the transfer of SP-simulated learning to clinical practice.

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Recommendations

Future studies should encompass the views of more training schools regarding the use of simulation as a learning strategy. The perceptions of nursing edu cators and staff in clinical practice, who interact with student nurses, should be ascertained so that potential shortcomings can be identified and addressed.

Study limitations

The data are closely bound to the context and are therefore not generalisable. Only students of one institution in a single study year were involved. This limits the broader applicability of the results even further. Acknowledgements. We wish to thank the School of Nursing, University of the Free State, for financial and logistical support, as well as the students who participated in the study. Author contributions. AJ: primary researcher, pilot study for a PhD dissertation. IV: supervisor, co-coding and co-author of article. Funding. None. Conflicts of interest. None.

1. McCormack B, McCance T. Person Centred Nursing: Theory and Practice. Oxford: Wiley-Blackwell, 2010:41-84. 2. Benner P, Sutphen N, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass, 2010:155-167. 3. Jacobs AC, van Jaarsveldt DE. ‘The character rests heavily within me’: Drama students as standardized patients in mental health nursing education. J Psychiat Mental Health Nursing 2016;23(3-4):198-206. https://doi. org/10.1111/jpm.12302 4. Lehr ST, Kaplan B. A mental health simulation experience for baccalaureate student nurses. Clin Simulation Nursing 2013;9(10):e425-e431. https://doi.org/10.1016/j.ecns.2012.12.003 5. Berragan L. Conceptualising learning through simulation: An expansive approach for professional and personal learning. Nurse Educ Pract 2013;13(4):250-255. https://doi.org/10.1016/j.nepr.2013.01.004 6. Jansen R, Venter I. Psychiatric nursing: An unpopular choice. J Psychiat Mental Health Nursing 2015;22(2):142-148. https://doi.org/10.1111/jpm.12138 7. Szpak JL, Kameg KM. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clin Simulation Nursing 2013;9(1):e13-e19. https://doi.org/10.1016/j.ecns.2011.07.003 8. Anderson M, Holmes TL, LeFlore JL, Nelson KA, Jenkins T. Standardized patients in educating student nurses: One school’s experience. Clin Simulation Nursing 2010;6(2):e61-e66. https://doi.org/10.1016/j.nedt.2015.03.004 9. Doolen J, Giddings M, Johnson M, de Nathan G, Badia OL. An evaluation of mental health simulation with standardized patients. Int J Nursing Educ Schol 2014;11(1):1-8. https://doi.org/10.1515/ijnes-2013-0075 10. Timmis C, Speirs K. Student perspectives on post-simulation debriefing. Clin Teach 2015;12(6):418-422. https:// doi.org/10.1111/tct.12369 11. Davis S, Josephsen J, Macy R. Implementation of mental health simulations: Challenges and lessons learned. Clin Simulation Nursing 2013;9(5):e157-e162. https://doi.org/10.1016/j.ecns.2011.11.011 12. Creswell JW. Research Design. 4th ed. London: Sage, 2014:183-213. 13. Shawler C. Standardized patients: A creative teaching strategy for psychiatric-mental health nurse practitioner students. J Educ 2008;47(11):528-531. https://doi.org/10.3928/01484834-20081101-08 14. Campbell SH, Daley KM. Simulation Scenarios for Nurse Educators. New York: Springer, 2009:8-10. 15. Wallace P. Coaching Standardized Patients for Use in the Assessment of Clinical Competence. New York: Springer, 2007:216-218. 16. Milisen K, de Busser T, Kayaert A, Abraham I, de Casterlé BD. The evolving professional nursing self-image of students in baccalaureate programs: A cross-sectional survey. Int J Nursing Studies 2010;47(6):688-698. https:// doi.org/10.1016/j.ijnurstu.2009.11.008

Accepted 13 December 2016.

Research

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

Understanding student early departure from a Master of Public Health programme in South Africa T Dlungwane,1 BSc (Physio), MPH; A Voce,1 PhD; R Searle,2 MA, MSc; J Wassermann,3 PhD 1

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

Department of Higher Education Studies, School of Education, University of KwaZulu-Natal, Durban, South Africa

Discipline of History Education, School of Education, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: T Dlungwane (dlungwane@ukzn.ac.za)

Background. Student departure from university without completing a qualification is a major concern in higher education. Higher Education South Africa reported that in undergraduate studies, 35% of students depart after the first year and only 15% of students who enrol complete their degree within the minimum permissible time. At postgraduate level, the departure from Masters programmes in South Africa (SA) ranged from 30% to 67% in 2010. Early departure refers to students who leave an academic programme within the first semester of commencing their studies. At one SA university, there were a total of 109 first-time Master of Public Health (MPH) student registrations in 2013 and 2014. By the end of the first semester in the respective years, a total of 27 students actively deregistered from the programme and 11 students did not sit the first-semester examinations, representing an aggregate 35% rate of early departure. The factors associated with early departure at the University of KwaZulu-Natal are not well understood. Objective. To understand factors associated with early departure in the MPH programme at the University of KwaZulu-Natal. Method. A mixed-methods design was implemented. Students who departed within the first semester of commencing the MPH programme in 2013/2014 were followed up. Data were collected using self-administered questionnaires and in-depth interviews. Results. Failure to balance work and academic obligations with poor time management, stress and academic demands related to the programme, and insufficient academic progress were found to be associated with student early departure from the MPH programme. Conclusion. Student early departure from the MPH programme was influenced by multifaceted factors. Senior students can mentor new students as early as possible in their programme. The orientation block should include development activities such as time management, stress management and effective study skills to assist mature students to cope with the demands of part-time postgraduate studies. Afr J Health Professions Educ 2017;9(3):111-115. DOI:10.7196/AJHPE.2017.v9i3.793

Student departure from universities without completing a qualification is a major concern for higher-education institutions.[1] Three-quarters of undergraduate students who terminate their studies prematurely leave during the first year, and most of those who depart do so during the first 6 weeks of the first semester.[2] Higher Education South Africa reported in 2009 that in undergraduate studies 35% of students depart after the first year and that only 15% of students who enrol complete their degrees within the minimum permissible time.[3] At postgraduate level, the rate of premature departure from Masters programmes in South Africa (SA) was estimated at 46% in 2013.[4] Premature departure varies across fields of study, and is higher for science and lower for arts, social science and legal studies.[5] The high number of students prematurely departing from higher education has a major impact on national resources and robs the labour market of highly skilled personnel.[6] In SA, a 20% premature departure rate for both undergraduate and postgraduate students costs the government ZAR1.3 billion each year. [6] Premature departure costs are not only borne by institutions, society and professions but also by students, who suffer financial, emotional and psychological consequences.[6] Despite the post1994 increase in access to higher education in SA, premature departure remains a critical issue for postgraduate programmes.[6] The process of premature departure from higher education is complex, and factors and reasons vary from student to student and from institution

to institution.[2,3] Furthermore, factors contributing to student departure during the first semester are different from factors associated with students leaving in the later years.[1,2,7] Leaving an academic programme before completing the first semester of study is referred to as ‘early departure’. Factors reported to influence early departure include financial constraints, poor academic progress, and incompatibility between the student and the institution.[2,7] Persistence and resilience during the first semester of the first year are viewed as crucial for students to succeed in higher education. [2,3,7] This article will examine early departure from the Master of Public Health (MPH) programme offered at one higher-education institution in KwaZuluNatal Province, SA. MPH programmes are structured to cater for a diverse, multidisciplinary and multiprofessional range of students. The programmes are aimed at equipping public health practitioners with collaborative strategies to address major risk factors contributing to the global and national burden of disease. The MPH under investigation comprises a 50% coursework and 50% research component. The qualification is offered only part-time over a period of 2 years, on a flexible modular system basis, with each module requiring an initial 2 - 3 days’ face-to-face contact at the beginning of the semester, and a subsequent 2 - 3 days’ face-to-face session later in the same semester. Students are expected to complete five core modules and one elective, of which four core modules should be completed

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Research within the first year. Ongoing interaction and module-related support are provided between contact sessions through the on-line learning system of the institution. In 2013 and 2014, 109 first-time MPH students were registered. By the end of the first semester in the respective years, a total of 27 students actively deregistered from the programme, while a total of 11 students did not sit the first-semester examinations. This represents an aggregate 35% early-departure rate. Understanding the reasons for the early departures will assist the programme in developing appropriate strategies to ensure greater student retention and throughput.

Objective

To investigate the factors contributing to early departure of students in the MPH programme at the University of KwaZulu-Natal in 2013 and 2014.

Methods

This was an exploratory study to describe the features of early-departure students. A mixed-methods research design was applied. All 38 students who were registered for first-year MPH studies in 2013 and 2014 and departed in the first semester were invited to participate in the study via email. Early-departure students were sent weekly reminders to complete the questionnaire by email for a period of 8 months, and those who had not responded were contacted by telephone. Firstly, data were collected using self-administered questionnaires electronically distributed to all early-departure students. The questionnaire consisted of closed-ended questions. Data were collected on demographics, educational and employment background, and programme-related, institutional and personal reasons for leaving the programme. The data were captured into Microsoft Excel 2003 (Microsoft, USA), and then exported into SPSS 15 (Microsoft, USA). The data were analysed using descriptive summary statistics. Secondly, from early-departure students who completed the selfadministered questionnaire, a convenience sample for in-depth interviews was drawn of respondents within reach and available and who responded positively to the invitation to be interviewed. An interview guide approach was implemented in face-to-face in-depth interviews until saturation was reached. A total of eight in-depth interviews were conducted. The purpose of the interviews was to gain further insights into the responses emanating from the self-administered questionnaires. The respondents were asked open-ended questions about their experiences as MPH students with regard to programme, institutional and personal characteristics. In addition, the interviewer sensitively enquired about the reasons that had influenced their departure from the programme. The interviews took about 30 minutes each, and were tape recorded and transcribed verbatim. Thematic analysis was used to analyse transcriptions. Coding was done and then emergent themes were identified. Trustworthiness of the findings was achieved through: (i) dependability; and (ii) triangulation. Dependability of the data collected was ensured through an audit trail. The main researcher and supervisor served as peer reviewers of the individual in-depth interviews, the level of probing, and the sequence in terms of how the data were collected. Triangulation of data was achieved through the use of individual in-depth interviews, field notes during the interviews and a self-administered questionnaire. Ethical approval was granted by the University of KwaZulu-Natal Human and Social Sciences Research Ethics Committee (ref. no. HSS/0561/014D), and permission to conduct the study was granted by the registrar.

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Results

Of the 38 early-departure students who were invited to participate, 25 (66%) returned the questionnaire. Of the 25 respondents, 19 (76%) were female and 14 (56%) were between the ages of 30 and 39 years. Twenty (80%) were employed in the public sector and 11 (44%) were clinicians (Table 1). All were in full-time employment. The age, gender and education background data for other graduates (non-responders) were available from the alumni records: females comprised 62%, 38% were aged 40 - 49 years, and 77% were clinicians. The profile of the respondents is in line with the report by the Council of Graduate Schools, which revealed a shift in the age distribution of postgraduate students in SA.[8] In 2007, 22% of all postgraduate students were â&#x2030;Ľ40 years of age, compared with 18% in 1987. Projections suggest that the number of mature students will continue to increase.[8]

Reasons provided for early departure from the MPH programme Respondents were asked what had influenced their decision to leave the programme. The most cited reason was heavy workload on the programme Table 1. Demographic and social characteristics of earlydeparture students (N=25) Categories

Respondents, n (%)

Age (yr) 20 - 29

3 (12)

30 - 39

14 (56)

40 - 49

6 (24)

â&#x2030;Ľ50

2 (8)

Gender Female

19 (76)

Marital status Married

17 (68)

Single

6 (24)

Widowed

1 (4)

Living with partner

1 (1)

Educational background Medical

8 (32)

Nursing

7 (28)

Allied science

8 (32)

Social science

2 (8)

Current position Programme manager

6 (24)

Middle manager

3 (12)

Medical manager

1 (4)

Researcher

1 (4)

Clinician

11 (44)

Academic

3 (12)

Current employment Public sector

20 (80)

NGO

1 (4)

Research

1 (4)

Academic

2 (12)

Research Table 2. Reasons provided by students for early departure from the Master of Public Health programme (N=25) Importance of reason, n (%) Not at all

A little

Moderately/very

The difficulty of the programme

6 (24)

13 (52)

The programme was not what I expected

11 (44)

5 (20)

9 (36)

The way the programme was taught did not suit me

9 (36)

6 (24)

10 (40)

The overall organisation of the programme

9 (36)

7 (28)

9 (36)

The timetabling of the programme did not suit my needs

9 (36)

6 (24)

10 (40)

Too heavy a workload on the programme

4 (16)

2 (8)

19 (76)

I felt I was making insufficient academic progress

7 (28)

11 (44)

Not enough time spent on studying outside timetabled sessions

8 (32)

3 (12)

14 (56)

Stress related to the demands of the programme

5 (20)

4 (16)

16 (64)

Lack of personal support from colleagues

12 (48)

3 (12)

10 (40)

The needs of dependants (e.g. family, partner)

13 (52)

4 (16)

8 (32)

Emotional difficulties involving others (e.g. family, partner, friend)

17 (68)

3 (12)

1 (4)

The demands of employment while studying

8 (32)

2 (8)

15 (60)

(76%), stress related to the demands of the programme (64%), demands of employment while studying (60%), not enough time spent on studies outside face-to-face sessions (56%), the difficulty of the programme (52%) and insufficient academic progress (44%) (Table 2). Analysis of the self-administered questionnaires and interviews with the early departures revealed three main and strongly inter-related reasons provided for withdrawing from the programme. The themes identified were balancing responsibilities and time management, stress and the demands of the MPH programme, and insufficient academic progress. Balancing responsibilities and time management Respondents reported that the decision to depart was influenced by not having enough time outside the face-to-face sessions to commit to their studies, within the context of heavy job demands. Conflicting demands, work/life balance, time management and student preparedness for post graduate studies were additonal factors that led to some respondents' decision to leave. ‘My job has timelines. Also, whatever assignment the lecturer gives you it has got timelines and all these people need you. Also at church there are timelines, you know. I was failing to balance all these three aspects in my life.’ (R2) ‘… it came to a point where, you know you get so exhausted at the end of the day working and then you get back home and then having to fit in time to go over your work and so I felt that was a challenge for me. I was not able to balance it, and I think I needed to have some skills development on how to have managed it [studying]. So perhaps the balancing act was not well done because of the lack of structured plan on how to go about it [managing the studies].’ (R4) ‘And to have time actually to do the assignments was quite difficult for me.’ (R3) Stress and the demands of the MPH programme The academic demands of the MPH programme were reported to cause stress and to contribute to early departure. Aggravating the inherently demanding academic programme were poorly managed peer-learning activities, personal factors, and anxieties about academic performance,

particularly in the case of students who had been absent from higher education for some time. ‘… it was quite heavy for me because there were lots of assignments to be done within a very short period, and also we have to work in groups and you find that people are not pulling their weight and you do more of the work and I was pregnant and was mindful that I do not want to be too stressed …’ (R3) ‘It was hectic and was actually stressing me and draining me. I did not think with that workload and the amount of work that I have to do I will be able to get the mark that they require for me to proceed.’ (R5) ‘I had not been studying for about 14 years, it was really difficult. It was like I am in a new land. I was struggling.’ (R2) Insufficient academic progress Fear of failure and insufficient academic progress were highlighted as contributing to early departure, exacerbated by unfamiliar subject matter and a lack of clarity regarding academic expectations. ‘… when it came to me having to prepare for my exam, I just felt lost. So I said to myself, there is no use in continuing with something that I do not understand now and do the next module. What if it happens again? It was actually the fear of failure again, I failed, and then what if I fail again? I have never failed in my life.’ (R8) ‘… I could not even pass and I think it discouraged me and yet I had made a good effort. I was trying my level best to get to there [passing], but when I tried so badly then I realised I have not even passed and yet I think I take out all my energy to go for it [studying].’ (R6)

Discussion

The characteristics of the sample of early-departure students indicate a profile of part-time mature, married women working as clinicians and managers in the public sector. Mature part-time postgraduate students are faced with numerous challenges such as adjusting to postgraduate demands when returning to higher education many years after obtaining an undergraduate qualification.[9,10] Four inter-related factors were foregrounded by the respondents as contributing to early departure in the MPH programme: a struggle on how

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Research to balance the demands of complex academic, personal and professional worlds, with competing demands on time, stress brought about by the academic demands of the MPH programme, and insufficient academic progress. The reasons cited for early departure are not unique to the respondents in this study.[7,10] The complex competing roles resulting from enrolling for a Master’s degree contributed to their decision to depart. The transition into postgraduate education brought about additional stress and time pressures that competed with existing personal and professional roles for time, space and mental energy.[11] Schlossberg[12] defines transition as an event that results in changed routine and roles. The change has a potential to cause stress and anxiety.[12] For mature students, the transition to postgraduate education usually brings conflict with existing roles and could lead to a questioning of the roles.[12] The process of adjustment to the new role of being a student requires appropriate preparation, support and a strong sense of self-belief.[12] The study participants were overwhelmed by the workload and the demands of the MPH programme. For many, failure to negotiate the learning demands and volume of work in the programme owing to lack of structured planning, time constraints, lack of preparedness and stresses led to a decision to leave the programme. Mature part-time students need structured support systems commencing at the pre-enrolment phase to ensure that they are socially and academically integrated into highereducation institutions and improve their persistence. Moreover, for students to be adequately integrated, mentoring by faculty staff and senior students coupled with academic and peer-support structures help students see beyond the immediate stresses to the future benefits studying will bring by identifying achievable goals.[13-15] Some participants in this study reported that inability to achieve satisfactory results to progress academically, coupled with difficulty in understanding the course material, resulted in their decision to leave the programme. They displayed an inability to overcome the academic setbacks and study pressure that tend to be associated with part-time mature students. The ability to overcome challenging circumstances and bounce back after experiencing failure requires a certain degree of academic resilience.[16] A growing body of research reports that students with high academic resilience and self-efficacy are more likely than those without to persist when confronted with difficult academic material, and that they perceive negative performance evaluations as challenges to overcome and as signposts indicating where learning needs to be deepened rather than as threats to avoid.[13,14,16] Most revealing from the data was that student departure is influenced by multifaceted factors. While 35% of students departed in the first semester, students with presumably equally pressing demands completed the degree. Further research must focus on a more nuanced understanding of the differences in characteristics between early-departure students, students who leave after the first semester but before completion, and completers. Moreover, an investigation of the influence of resilience and self-efficacy on the persistence of MPH students needs to be conducted. Although financial constraints and incompatibility between the student and the institution have been reported in the literature as factors that influence early departure, these factors did not surface in this study.

Study limitations

This study was conducted in a single MPH programme, and results cannot be generalisable to students in other MPH programmes, although they

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may be transferrable to MPH programmes with part-time mature students in SA. Further research of a similar nature that compares early-departure students across different programmes in the country is recommended. The non-respondents may have had different reasons for early departure from the MPH programme.

Conclusion

This study sought to understand early departure in an MPH programme. Student early departure in the programme was seen to be influenced by four interrelated factors contributing to early departure: balancing the world of work and academics and poor time management, stress and academic demands related to the programme, and insufficient academic progress. Further research needs to focus on student transition into postgraduate education, approaches implemented to help students cope with academic workload, and methods employed to help students deal with insufficient academic progress experienced once they are registered. Furthermore, research is needed to understand the coping mechanisms used by parttime mature students at the commencement of their studies. Strategies to assist students to cope with the challenges that they encounter need to be structured within the MPH programme. Orientation and induction should include students’ development activities such as time management, stress management and effective study skills. Creating structured supportive systems, and providing mentorship by senior students as an ongoing process, could assist mature students in dealing with the life changes that studying brings. This can be accomplished using a number of methods, such as inviting faculty staff and past students who struggled initially and eventually completed the MPH programme to serve as mentors to students registering for the first time. Acknowledgements. The authors thank the MPH students for participating in the study. Author contributions. TD had the primary responsibility for the drafting of the manuscript. TD, AV, RS and JW all contributed substantially to the intellectual content and finalisation of the manuscript. All the authors read and approved the final manuscript. Funding. This publication was made possible by grant no. R24TW008863 from the Office of the US Global AIDS Coordinator and the National Institutes of Health (NIH), US Department of Health and Human Services (NIH Office of Aids Research and NIH Office of Research on Women’s Health). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the USA government. Conflicts of interest. None. 1. Hovdhaugen E. Transfer and dropout: Different forms of student departure in Norway. Stud High Educ 2009;34(1):1-17. https://doi.org/10.1080/03075070802457009 2. Elkins S, Braxton J, James G. Tinto’s separation stage and its influence on first-semester college student persistence. Res High Educ 2000;41(2):251-268. https://doi.org/10.1023/A:1007099306216 3. Council on Higher Education, South Africa. The State of Higher Education in South Africa. Pretoria: CHE, 2009. http://www.che.ac.za/media_and_publications/higher-education-monitor/higher-education-monitor-8-statehigher-education (accessed 20 March 2016). 4. Council on Higher Education, South Africa. VitalStats: Public Higher Education 2013. Pretoria: CHE, 2015. http://www.che.ac.za/media_and_publications/.../vitalstats-public-higher-education-2013 (accessed 14 July 2016). 5. Scott G, Shah M, Grebennikov L, Singh H. Improving student retention: A University of Western Sydney case study. J Inst Res 2008;14(1):1-8. http:// files.eric.ed.gov/fulltext/EJ1055597 (accessed 10 March 2016). 6. National Department of Education, South Africa. National Plan for Higher Education. Pretoria: NDoE, 2001. http:/ https://www.dhet.gov.za/HED/Policies/National Plan on Higher Education (accessed 24 February 2015). 7. Longden B. Leaving College Early: A Qualitative Case Study. England: Higher Education Funding Council for England, 2001. http://www.academia.edu (accessed 1 August 2015). 8. Bell NE. Data Sources: Non-Traditional Students in Graduate Education. Washington, DC: Council of Graduate Schools, 2009. http://cgsnet.org/ckfinder/userfiles/files/DataSources_2009_12.pdf (accessed 20 November 2015). 9. Chikoko V. First year Master of Education (M.Ed.) students' experiences of part-time study: A South African case study. S Afr J High Educ 2010;24(1):32-47. https://eric.ed.gov/?id=EJ936979 (accessed 8 March 2016).

Research 10. Koen C. Postgraduate student retention and success: A South African case study. PhD thesis. Cape Town: University of Western Cape, 2007. 11. Abrahams MA. Making sense of part-time studentsâ&#x20AC;&#x2122; transition into higher education: Recognising the self, family and work. Int J Humanit Soc Sci 2013;3(21):201-211. 12. Schlossberg NK. Counseling Adults in Transition: Linking Practice with Theory. Baltimore: Springer Publishing Company, 2005. 13. Wilks SE. Resilience amid academic stress: The moderating impact of social support among social work students. Adv Soc Work 2008;9(2):106-125. 14. Culpepper AS. Women graduates academic resilience and their personal strategies for doctoral success. Florida International University, 2004. http://digitalcommons.fiu.edu/dissertations/AAI3165156 (accessed 21 June 2017).

15. Martin AJ. Motivation and academic resilience: Developing a model for student enhancement. Aust J Educ 2002;46(1):34-49. https://doi.org/10.1177/000494410204600104 16. Taylor H, Reyes H. Self-efficacy and resilience in baccalaureate nursing students. Int J Nurs Educ Scholarsh 2012;9(1):1-13. https://doi.org/10.1515/1548-923X.2218

Accepted 21 February 2017.

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

Postgraduate trainees’ perceptions of the learning environment in a Nigerian teaching hospital P I Idon,1 BDS, FMCDS; I K Suleiman,1 BDS; H O Olasoji,1,2 BSc, BChD, FMCDS, FWACS, MSc Med Educ (UK); Z Mustapha,3 MBBS, FWACS; H M Abba,1 BDS 1

Department of Dental Surgery, University of Maiduguri Teaching Hospital, Nigeria

Department of Oral and Maxillofacial Surgery and Oral Pathology, Faculty of Dentistry, College of Medical Sciences, University of Maiduguri, Nigeria

Department of Radiology, College of Medical Sciences, University of Maiduguri Teaching Hospital, Nigeria

Corresponding author: P I Idon (idonp85@gmail.com)

Background. The learning environment represents various factors that describe the learner’s experiences in that setting. The learning environment of junior doctors undergoing training programmes in hospitals is considered a major factor determining both academic success and health service delivery performance. Increased performance in both areas requires routine assessment of the learning environment to identify components that need attention. Objective. To evaluate the perception of junior doctors undergoing specialist training regarding the learning environment in a teaching hospital. Methods. This was a single-centre, cross-sectional study, using the Postgraduate Hospital Educational Environment Measure (PHEEM). The questionnaire was used to collect data on the learning environment of junior doctors in all 10 clinical departments at the University of Maiduguri Teaching Hospital, Nigeria. All of the junior doctors (n=148) in the hospital at the time of the study received the questionnaire; they constituted the sample size for the survey. Data collected were analysed to assess junior doctors’ perceptions of the overall learning environment and of the individual factors in the learning environment as measured by the individual items of PHEEM. Results. The hospital educational environment was rated high, with a score of 98.25. The domains of the environment measure also showed positive perceptions, but revealed specific areas in need of attention as measured by the items of the questionnaire. Significant (p<0.05) differences were noted in the perceptions of some items of the environment in the clinical departments. Conclusions. The junior doctors’ perceptions of their educational environment were positive. The study was able to identify areas of strengths and weaknesses in the overall hospital learning environment and the specialty departments. Overall, it identified the absence of an informative handbook for junior doctors and quality accommodation and catering facilities when the doctors were on call, as well as excess workload and lack of counselling services as areas that require the most attention to improve the learning environment. Afr J Health Professions Educ 2017;9(3):116-122. DOI:10.7196/AJHPE.2017.v9i3.786

The West African College of Surgeons (WACS), West African College of Physicians (WACP) and the National Postgraduate Medical College of Nigeria (NPMCN) regulate the postgraduate medical and dental education [1,2] in the West African region and Nigeria, respectively. Currently, progress report forms are completed annually by the trainers, i.e. specialist physicians and surgeons in the various teaching hospitals, to assess the progress of postgraduate training of junior doctors. At regular intervals, the colleges visit these hospitals to assess the facilities for postgraduate training for the purpose of maintaining the standard of training and re-accreditation of the institution for continued training of junior doctors. The term junior doctor in this regard refers to all cadres of doctors, except specialist physicians or surgeons who are fellows of any of the postgraduate medical colleges. These include senior resident doctors, junior resident doctors, medical officers, senior house officers and house officers. The resident doctors are those undergoing the residency training programme in various specialties to become specialist physicians or surgeons under the supervision of consultants. Medical officers, although not enrolled in the residency training programme, also work under and learn from the specialists. The senior house officers and house officers are

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junior doctors at different stages of their pre-registration and compulsory supervised training after graduation from medical school. The specialist physicians and surgeons are appointed as consultants in the teaching hospitals to consult and oversee the training of junior doctors. To date, these assessments only focused on the trainees’ progress and did not take into consideration their perceptions of the trainers and other components in the environment in which they work, and how these affect their learning. The learning environment or educational environment has been considered to encompass physical (safety, food, shelter, comfort), emotional (security, feedback from trainers, absence of bullying and harassment) and intellectual (learning with patients, relevance to practice, evidence-based, [3] active participation by learners) aspects. Working and learning in a clinical environment represent a challenging phase for doctors in training. Junior doctors in this environment have to achieve a balance between a myriad of things, including care for their patients, adhering to their work schedules, dealing with the loss of a patient, and continuing with their academic pursuits, along with an obligation to [4] their family, and their personal life. The type or quality of the learning environment in a teaching hospital affects the motivation for clinical

Research [5,6]

training, knowledge base and performance of junior doctors. The teaching hospital has the responsibility of providing satisfactory education for its junior doctors, with the aim of improving the services they render to [7] the public. Since recognising the importance of the quality of the learning environment of teaching hospitals in postgraduate medical education, the [8-10] Problems of topic has received increased attention in the literature. junior doctors in the learning environment have been noted to include lack of clear objectives regarding the curriculum and its scope. The focus has been on knowledge acquisition, with little emphasis on problem-solving skills. Other problems noted have included high workload, leaving little time for academic activities, as well as the more talked-about teaching-by[11] humiliation method employed by trainers. [12] Roff constructed and validated the Postgraduate Hospital Educational Environment Measure (PHEEM) for hospital-based junior doctors in the UK. This tool is considered reliable for evaluating the quality of the educational environment of teaching hospitals, and has been used to measure the educational environment for junior doctors in several [5,6,12,13] The lack of empirical data means that little is known countries. about the way junior doctors perceive their learning environment. Also, it provides an additional needed input on facilities and learning environment as perceived by the trainees. Postgraduate regulatory bodies may use this as part of the assessment tools for the accreditation and re-accreditation of teaching hospitals for the training of junior doctors. The aim of this study was therefore to evaluate the perceptions of junior doctors regarding the learning environment at the University of Maiduguri Teaching Hospital (UMTH), Nigeria, by using PHEEM. The results of this study can serve as a basis for improvement and for future evaluation/comparison of trainees’ perceptions of Nigerian postgraduate medical and dental education. The study therefore set out to determine: • the junior doctors’ perceptions of the hospital learning environment at UMTH • the effect of area of specialty on the perceptions of the learning environment • the effect of gender on the perceptions of the learning environment.

Methods

Study setting

The study was conducted at UMTH, which is the main tertiary health centre in North-Eastern Nigeria. It is located in Maiduguri, a semi-urban settlement and the capital of Borno State. The hospital serves as a major referral centre for the North-Eastern states and as a training centre for junior doctors in several specialties. Currently, the hospital carries out training of junior doctors in 10 specialty departments: dental surgery, general outpatients, ophthalmology, ear nose and throat, internal medicine, obstetrics and gynaecology, paediatrics, pathology, radiology and surgery.

Study design and recruitment of participants

The study employed a cross-sectional research approach in assessing the perceptions of the participants with regard to the hospital learning environment. Employing a census survey method of sampling, all doctors below the grade rank of consultant in the various hospital departments and specialties at the time of the study in 2014 were included and constituted the study population. These included the resident doctors, medical officers, senior house officers and house officers. The participants were recruited individually into the study in their departments following an introduction of the objective of the study.

Data collection method

The study used two self-administered questionnaires to collect data from the participants. The first consisted of short structured questions constructed to collect demographical information, such as the participant’s gender, age group, training grade, year in current grade and specialty. Information on the participant’s perception of the hospital’s learning environment was collected with the PHEEM questionnaire. The researchers distributed questionnaires to all the participants by hand and retrieved the completed questionnaires in the same way. To achieve confidentiality, the data obtained from the participants did not include their names and therefore cannot be linked to any individual participant. PHEEM, as an assessment tool for the learning environment, is simple and practical, taking ˂5 minutes to complete, and has been validated in several studies, with reliability values of 0.92 and 0.93 using Cronbach’s alpha.[6,12,13] The questionnaire consists of 40 items with regard to learning environment, divided into three subscales, i.e. perception of role autonomy; perception of teaching; and perception of social support. Responses to each statement were indicated on a 5-point Likert scale as follows: 0 for strongly disagree, 1 for disagree, 2 for uncertain, 3 for agree and 4 for strongly agree. The maximum possible score is 4 or 160 and the minimum is 0 for item score and overall scores, respectively, with higher scores indicating a better educational environment. Four of the 40 items (items 7, 8, 11 and 13) are negative statements and were scored in reverse. Three of the items were modified to suit the context in which the study was being carried out. Item 7 (‘There is racism in this post’) was not applicable, as most of the junior doctors are Nigerians, but of different tribes. The item was therefore modified to read, ‘There is racism/tribalism in this post’. Item 11 (‘I am bleeped inappropriately’) was also modified because junior doctors are either required to stay in the emergency department or call rooms when on duty, or are fetched at their residence in the hospital quarters when the need arises. This was modified to read, ‘I am called inappropriately’. Also, item 17 was modified to read, ‘My hours of work conform to the civil service rule’, as applicable in the country. Data analysis Analysis of the data obtained was performed using the Statistical Package for Social Sciences (SPSS) version 17.0 (SPSS Inc., USA). Descriptive statistics were reported in the form of frequencies, percentages, means, and standard deviations (SDs). Student’s t-test was used to compare the item mean and overall PHEEM scores between the genders, while analysis of variance (ANOVA) statistics was used to analyse mean scores of items and overall scores among the training grades and specialties. Statistical significance was inferred at p<0.05.

Ethical approval

The Research and Ethical Committee of the hospital approved the study (ref. no. UMTH/REC/17/0089) before commencement. A detailed explanation was given to each participant, with assurance of confidentiality regarding data collection and analysis. To achieve such confidentiality, names of participants were not included in the data collected. In data analysis, participants were assured that information provided will be deidentified by aggregating responses of individuals into groups and reporting them as means and SDs. Participation was voluntary, with consent sought and obtained from each participant included in the study.

Results

Of the 148 participants, 108 (66 males and 42 females) completed and returned the questionnaires – a response rate of 73%. Data were received

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Research from all 10 specialty departments of the hospital. The highest response rates were recorded from the ophthalmology, radiology and dental specialties, and the lowest rate (50%) from the surgery specialty. The number of junior doctors in the specialty areas ranged from 2 to 17, distributed among the various cadres of junior doctors, house officers, senior house officers, medical officers, junior registrars and senior registrars (Table 1). The mean scores and SDs of the 40 items of the PHEEM questionnaire are shown in Table 2. The lowest item score was 1.08 for item 26 (‘There are adequate catering facilities when I’m on call’), while the highest was 3.16 (‘I have good collaboration with other doctors in my grade’). Items 9 and 32 were scored less than average (2.0) in the perception of the autonomy domain. Items 20, 26 and 38, relating to social support, were also ˂2.0. These items indicate problem areas in the learning environment. All other items had scores within the range of 2 - 3 (‘A more supportive/suitable educational environment, but with need for enhancement’), while only item 29 (‘I feel part of a team working here’) in the autonomy section and items 7, 13 and 16 in the social support section had scores >3.0. An overall score of 98.25 was obtained, with a score of 34.52 for perception of autonomy, 37.91 for perception of teaching and 25.76 for perception of social support (Table 3). Also shown in Table 3 are the various domain scores and overall scores for the different specialties. More items were reported with below-average scores in the obstetrics and gynaecology and paediatrics specialties, while dental surgery and ophthalmology did not score less than average for any of the items (Table 4). Table 1. Demographic distribution of the participants (N=108) Demographic distribution

Frequency (%)

Gender Male

66 (61.1)

Female

42 (38.9)

Total

108 (100)

Training level House officer

26 (24.1)

Senior house officer

5 (4.6)

Medical officer

22 (20.4)

Junior registrar

36 (33.3)

Senior registrar

19 (17.6)

Total

108 (100)

Specialty

118

Dental surgery

16 (14.8)

Medicine

14 (13.0)

Obstetrics and gynaecology

10 (9.3)

Pathology

9 (8.3)

Paediatrics

17 (15.7)

Surgery

10 (9.3)

Radiology

14 (13.0)

Ophthalmology

2 (1.9)

Ear, nose and throat

3 (2.8)

General outpatient department

13 (12.0)

Total

108 (100)

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Using Kruskal-Wallis (data normally distributed) one-way analysis of variance (ANOVA), comparison of these scores among the specialties and the training grades did not show any statistically significant difference, with p=0.055 and p=0.478, respectively. The Mann-Whitney U-test for domain (perception of role autonomy, p=0.796; perception of teaching, p=0.186; perception of social support, p=0.867) and overall scores between the genders also did not show statistically significant differences (p=0.592). However, differences were noticed using one-way ANOVA in item scores among the specialties (Table 5). Post-hoc analysis using the Tukey honest significance difference (HSD) (equal variance assumed) and Games-Howell (equal variance assumption not met) statistics revealed the specialties with significant differences. Junior doctors in radiology had a significantly better perception (mean 3.29 (SD 0.47)) of the appropriate level of responsibility (item 5) compared with those in internal medicine (2.14 (1.01)). Dental surgery (1.19 (0.98)) and internal medicine (1.21 (1.12)) specialties rated item 9 significantly lower than obstetrics and gynaecology (2.80 (0.92)). The doctors in radiology (3.07 (0.73)) and obstetrics and gynaecology (3.50 (0.71)) gave significantly better ratings to item 14 than respondents from internal medicine (1.86 (1.09)), dental surgery (2.19 (1.11)) and paediatrics (2.12 (0.93). The perceptions of junior doctors in ophthalmology (3.00 (0.00)) and radiology (3.14 (0.77)) about their hours of work conforming to the civil service rule were significantly better than those of their colleagues in internal medicine (2.00 (0.96)) and surgery (1.10 (0.88)). Item 26 revealed a statistically significant difference among the specialties (p=0.013). A posthoc Tukey HSD test revealed a significant difference between respondents in radiology (2.00 (1.24)) and those in obstetrics and gynaecology (0.50 (0.71)) and surgery (0.60 (0.52)) regarding the quality of the catering service while on call. Paediatric (1.29 (1.21)) and obstetrics and gynaecology (0.60 (1.00)) specialties had a greater level of disagreement with item 32 (‘My workload in this job is fine’) compared with the response from dental surgery (2.81 (1.05)), pathology (2.78 (0.67)), radiology (2.79 (0.80)) and ophthalmology (3.00 (0.00)). Respondents from ophthalmology (3.00 (0.00)) rated the mentoring skills of their teachers significantly higher than the junior doctors in paediatrics (2.00 (1.06)) and there was also better feedback from them than from junior doctors in the general outpatient department (GOPD) (1.85 (0.99)).

Discussion

This study used PHEEM to assess the educational environment of junior doctors in a teaching hospital setting involving all the specialty departments. It also included junior doctors who are not yet in the residency programme, e.g. medical officers, senior house officers and house officers. From the results it was evident that PHEEM is a reliable tool for assessing the strengths [14] and weaknesses of the postgraduate hospital training environment. The learning environment in the hospital was valued fairly well by the junior doctors, but with room for improvement, as shown by a score of 98.25, corresponding to the ‘more positive than negative environment’ [12] according to the criteria proposed by PHEEM. The three subscale scores also revealed that there was a more positive perception towards the role of autonomy, and that the perceptions of teaching were moving in the right direction. Furthermore, it was found that the perceptions of social support had more positives than negatives. The lowest recorded item score was 1.08 (item 26: ‘There are adequate catering facilities when I am on call’) and the highest was 3.16 (item 16: ‘I

Research Table 2. Mean scores of each item of the PHEEM questionnaire Item

Domain

Mean (SD)

Perception of role of autonomy 1

I have a contract of employment that provides information about hours of work

2.20 (1.17)

I had an informative induction programme

2.07 (1.13)

I have the appropriate level of responsibility in this post

2.81 (0.98)

I have to perform inappropriate tasks

2.38 (1.15)

There is an informative junior doctorsâ&#x20AC;&#x2122; handbook

1.75 (1.08)

I am called inappropriately

2.56 (1.05)

There are clear clinical protocols in this post

2.44 (1.00)

My hours of work conform to the civil service rule

2.19 (1.22)

I have the opportunity to provide continuity of care

2.86 (0.63)

I feel part of a team working here

3.01 (0.83)

I have opportunities to acquire appropriate practical procedures for my grade

2.81 (0.83)

My workload in this job is fine

1.96 (1.30)

The training in this post makes me feel ready to be a senior registrar/consultant

2.62 (0.92)

My clinical teachers promote an atmosphere of mutual respect

2.82 (0.98)

Perception of teaching 2

My clinical teachers set clear expectations

2.73 (1.01)

I have protected educational time in this post

2.21 (1.11)

I have good clinical supervision at all times

2.28 (1.11)

My clinical teachers have good communication skills

2.94 (0.86)

I am able to participate actively in educational events

2.82 (0.91)

My clinical teachers are enthusiastic

2.80 (0.83)

There is access to an educational programme relevant to my needs

2.16 (1.06)

I get regular feedback from seniors

2.48 (0.89)

My clinical teachers are well organised

2.51 (1.05)

I have enough clinical learning opportunities for my needs

2.03 (1.13)

My clinical teachers have good teaching skills

2.91 (0.76)

My clinical teachers are accessible

2.77 (0.97)

Senior staff utilise learning opportunities effectively

2.25 (0.93)

My clinical teachers encourage me to be an independent learner

2.74 (0.97)

My clinical teachers provide me with good feedback on my strengths and weaknesses

2.28 (1.05)

Perception of social support 7

There is racism/ tribalism in this post

3.03 (1.02)

There is sex discrimination in this post

3.07 (1.04)

I have good collaboration with other doctors in my grade

3.16 (0.63)

I have suitable access to careers advice

2.25 (1.09)

This hospital has good-quality accommodation for junior doctors, especially when on call

1.79 (1.24)

I feel physically safe within the hospital environment

2.69 (0.98)

There is a no-blame culture in this post

2.06 (1.09)

There are adequate catering facilities when I am on call

1.08 (1.09)

My clinical teachers have good mentoring skills

2.53 (0.97)

I get a lot of enjoyment out of my present job

2.29 (1.00)

There are good counselling opportunities for junior doctors who fail to complete their training satisfactorily

1.90 (1.18)

PHEEM = Postgraduate Hospital Educational Environment Measure; SD = standard deviation.

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Research Table 3. Subscale and overall PHEEM scores of the different specialties Score

Assessment

Dental surgery

Medicine

O&G

Pathology

Paediatrics

Surgery

Radiology

Ophthalmology

ENT

GOPD

35.1

30.4

36.0

38.1

32.2

40.6

36.5

32.7

32.9

38.3

34.0

39.4

40.9

33.8

40.4

44.2

41.0

40.3

33.9

26.9

24.4

24.2

25.1

24.1

26.6

30.3

27.5

29.0

23.8

100.3

88.8

99.6

104.1

90.1

99.2

115.1

105

102

90.6

Mean (SD)

Perception of role of autonomy 0 - 14

Very poor

15 - 28

A negative view of one’s role

29 - 42

A more positive perception of one’s job

43 - 56

Excellent perception of one’s job

34.5 (7.3)

Perception of teaching 0 - 15

Very poor

16 - 30

In need of some training

31 - 45

Moving in the right direction

46 - 60

Model teachers

37.9 (8.8)

Perception of social support 0 - 11

Not existent

12 - 22

Not a pleasant place

23 - 33

More pros than cons

34 - 44

A good supportive environment

25.8 (5.6)

Overall 0 - 40

Very poor

41 - 80

Plenty of problems

80 - 120

More positive than negative

121 - 160

Excellent

98.3 (20.0)

PHEEM = Postgraduate Hospital Educational Environment Measure; O & G = obstetrics and gynaecology; ENT = ear, nose and throat; GOPD = general outpatient department; SD = standard deviation.

Table 4. Items rated below average by the different specialties Specialty

Items with scores ˂2.0

Dental surgery

Ear, nose and throat

17, 20

General outpatient department

Medicine

20, 25

Obstetrics and gynaecology

17, 19, 20, 32

Ophthalmology

Paediatrics

20, 23, 25, 36

Pathology

20, 25

Radiology

Surgery

120

September 2017, Vol. 9, No. 3 AJHPE

have good collaboration with other junior doctors’). The majority of the items (31 of 40) had mean scores between 2 and 3, with only four items scoring >3 (7, 13, 16 and 29). These results highlight that the majority of the areas in the learning environment need improvement. However, it is also good to know that the areas where the junior doctors were most satisfied with their environment border on racism and tribalism, sex discrimination, collaboration with other junior doctors and sense of belonging to a team. [15] In a study by Vieira, it was noted that the residents also had a positive perception of the learning environment in terms of gender and racism. [16] Clapham et al. reported similar findings in a small sample of intensivecare residents in a hospital in the UK. Weaknesses identified in the environment, as indicated by a mean score of ˂2, appeared in five items (9, 20, 26, 32 and 38). This signifies that there was no information booklet available for junior doctors to orientate them with regard to the postgraduate programme. Moreover, other weaknesses

Research Table 5. Analysis of the differences in item scores among the specialties Item number

Statement

F-value

p-value

I have the appropriate level of responsibility in this post

2.545

0.011

There is an informative junior doctors’ handbook

3.096

0.003

There are clear clinical protocols in this post

3.551

0.001

My hours of work conform to the civil service rule

3.023

0.003

There are adequate catering facilities when I am on call

2.498

0.013

My workload in this job is fine

5.559

<0.001

My clinical teachers have good mentoring skills

2.489

0.013

My clinical teachers provide me with good feedback on my strengths and weaknesses

1.999

0.047

were: inadequate accommodation and catering facilities when on call, [15] excessive workload and absence of good counselling opportunities. Vieira reported low scores in four of these areas, suggesting lack of professional and [14] personal support in the learning environment. Similarly, Al-Sheikh et al. reported the lowest scores for catering, housing, information and guidance. The absence of adequate orientation of junior doctors at the beginning of their training, as seen with the low score for item 9, may have an effect on their learning, as this could result in difficulties in making informed choices in career paths from peculiarities of the different clinical rotations. An information handbook detailing the job description for every member of the [14] health team could reduce the possibility of exploitation. It is interesting to note that three of these items (20, 26 and 38) are in the domain of the perception of social support. The results of these items revealed that the educational environment is weak in the area of social support. There was general agreement among the departments with regard to item 20 (‘This hospital has good-quality accommodation for junior doctors, especially when on call’) as 9 of the 10 specialties scored it ˂2.0 (Table 4). These three items in the social support domain, and the low score for item 32 (‘My workload in this job is fine’), may support the association between the residency training programme and stress, depression and burnout, which are thought to be mainly due to excessive working hours, sleep deprivation, challenging patients and an aggressive and challenging [17-19] To improve the learning environment of the work environment. doctors in this study, attention should be given to the following focus areas: developing and providing the junior doctors with an information handbook, improving the quality of the accommodation, improving the catering facilities, finding a way to reduce the workload, and providing counselling [20] in a recent for the junior doctors if needed. Lleras and Durante, study, found a significant negative correlation between the educational environment and burnout among resident doctors, using PHEEM and Maslach Burnout Inventory questionnaires. The approach to reducing burnout in residents should include other components of the working environment, as a reduction in the workload alone has been found to be [21] unsuccessful. Analysis of the overall scores and subscale scores for level of training, gender and specialty department revealed no significant difference in the [22] overall and subscale scores. Khoja reported a significantly better perception of the learning environment by the junior doctors in their last year of training compared with those in the first 3 years. Possible reasons were reduced workload, greater contact time with their trainers, and increased [16] supervision and feedback from their trainers. However, Clapham et al. found that senior house officers scored the learning environment better

[6]

than other junior doctors who are ahead of them in training. Boor et al., [16] with similar results as Clapham et al., explained that the house officers and senior house officers may have a better perception of the learning environment, as they have lesser responsibilities and stress compared with those faced by other junior doctors who are ahead of them in training. The differences noted in the results of the abovementioned studies may be due to varying regulations regarding duties and workload for the levels of trainees [23] in different institutions. Kanashiro et al., as in the current study, did not find significant differences in the perception of the learning environment among the house officers, senior house officers and the other junior doctors who are ahead of them in training level. However, the authors noted signifi[12-14] did cant gender differences in the scores. Our study and other studies not find significant gender differences in PHEEM scores. Although all the specialties or departments were in the same hospital, there was a significant difference in their perceptions of some aspects of the learning environment, as seen, for example, with items 9, 17, and 32, where the junior doctors in dental surgery, internal medicine, ophthalmology, radiology, paediatrics and obstetrics and gynaecology had significantly different perceptions, respectively, than their counterparts in other specialties. These differences may reflect variations in the organisation and use of set protocols in the departments, as well as staff strength and workload assigned to individuals. Some specialties may make increased demands on the time of the junior doctors. This may explain why junior doctors in paediatrics and obstetrics and gynaecology reported a significantly greater [24] level of disagreement with their workload. Algaidi also noted differences in the perceptions of the learning environment among specialties in the same hospital, where he reported a significantly better perception of the learning environment by the junior doctors in general surgery compared with those in internal medicine. According to Algaidi,[24] this is an indication that the learning environment in each department is as important as the general hospital environment, which may have significant effects on the quality of the learning environment.

Conclusion

This study has identified areas of strengths and weaknesses in the hospital educational environment and the 10 individual specialty departments in the same hospital. Interventions in the areas of weaknesses identified should be implemented and followed up with regular assessments of the educational environment using PHEEM as a means of quality control. Although this study presented findings from only one hospital, the results could assist other curriculum developers in the country’s postgraduate medical training programmes in assessing their learning environment, making comparisons

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Research and introducing measures to improve the environment for the training of junior doctors. This is important, as the quality of the junior doctors’ experiences in the learning environment relates to the quality of training and therefore the quality of care received by the patients they care for. Acknowledgements. None. Author contributions. PII: study idea, development of the study idea, experimental design, and preparation of the manuscript; KIS: collected data, evaluated statistics and contributed to discussion; HOO: further development of the study idea, development of experimental design and proofreading of the manuscript; ZM: proofreading of the manuscript and development of experimental design; and HMA: collected data, prepared results from statistical evaluation and contributed to manuscript preparation. Funding. None. Conflicts of interest. None. 1. West African Postgraduate Medical College. Profile of the college. http://www.wapmc.org/about (accessed 18 February 2016). 2. National Postgraduate Medical College of Nigeria. President’s speeches: Welcome NPMCN. http://www.npmcn. edu.ng/welcome-to-npmcn (accessed 18 February 2016). 3. Chambers R, Wall D. Teaching Made Easy: A Manual for Health Professionals. Abingdon, UK: Radcliffe Medical Press, 2000. 4. Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: A national survey of working conditions. JAMA 1998;279(15):1194-1199. https://doi.org/10.1001/jama.279.15.1194 5. Shimizu T, Tsugawa Y, Tanoue Y, et al. The hospital educational environment and performance of residents in the general medicine in-training examination: A multicenter study in Japan. Int J Gen Med 2013;6(1):637-640. https://doi.org/10.2147/IJGM.S45336 6. Boor K, Scheele F, van der Vleuten CP, Scherpbier AJ, Teunissen PW, Sijtsma K. Psychometric properties of an instrument to measure the clinical learning environment. Med Educ 2007;41(1):92-99. https://doi.org/10.1111/ j.1365-2929.2006.02651.x 7. Hoff TJ, Pohl H, Bartfield J. Creating a learning environment to produce competent residents: The roles of culture and context. Acad Med 2004;79(6):532-539. https://doi.org/10.1097/00001888-200406000-00007 8. Kendall ML, Hesketh EA, Macpherson SG. The learning environment for junior doctor training – what hinders, what helps. Med Teach 2005;27(7):619-624. https://doi.org/10.1080/01421590500069710

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9. Cross V, Hicks C, Parle J, Field S. Perceptions of the learning environment in higher specialist training of doctors: Implications for recruitment and retention. Med Educ 2006;40(2):121-128. https://doi.org/10.1111/j.13652929.2005.02382.x 10. Wall D, Clapham M, Riquelme A, et al. Is PHEEM a multi-dimensional instrument? An international perspective. Med Teach 2009;31(11):e521-e527. https://doi.org/10.3109/01421590903095528 11. Rotem A, Bloomfield L, Southon G. The clinical learning environment. Isr J Med Sci 1996;32(9):705-710. 12. Roff S, McAleer S, Skinner A. Development and validation of an instrument to measure the postgraduate clinical learning and teaching environment for hospital-based junior doctors in the UK. Med Teach 2005;27(4):326-331. https://doi.org/10.1080/01421590500150874 13. Aspegren K, Bastholt L, Bested KM, et al. Validation of the PHEEM instrument in a Danish hospital setting. Med Teach 2007;29(5):498-500. https://doi.org/10.1080/01421590701477357 14. Al-Sheikh MH, Ismail MH, Al-Khater SA. Validation of the postgraduate hospital educational environment measure at a Saudi university medical school. Saudi Med J 2014;35(7):734-738. 15. Vieira JE. The postgraduate hospital educational environment measure (PHEEM) questionnaire identifies quality of instruction as a key factor predicting academic achievement. Clinics 2008;63(6):741-746. https://doi. org/10.1590/S1807-59322008000600006 16. Clapham M, Wall D, Batchelor A. Educational environment in intensive care medicine: Use of Postgraduate Hospital Educational Environment Measure (PHEEM). Med Teach 2007;29(6):184-191. https://doi. org/10.1080/01421590701288580 17. Al-Marshad S, Alotaibi G. Evaluation of clinical education environment at King Fahad Hospital of Dammam University using the Postgraduate Hospital Education Environment Measure (PHEEM) Inventory. Educ Med J 2011;3(2):e6-e14. https://doi.org/10.5959/eimj.3.2.2011.or1 18. Collier VU, McCue JD, Markus A, Smith L. Stress in medical residency: Status quo after a decade of reform? Ann Intern Med 2002;136(5):384-390. https://doi.org/10.7326/0003-4819-136-5-200203050-00011 19. Peterlini M, Tiberio IF, Saadeh A, Pereira JC, Martins MA. Anxiety and depression in the first year of medical residency training. Med Educ 2002;36(1):66-72. https://doi.org/10.1046/j.1365-2923.2002.01104.x 20. Lleras J, Durante E. Correlation between the educational environment and burn-out syndrome in residency programs at a university hospital. Arch Argent Pediatr 2014;112(1):e6-e11. https://doi.org/10.5546/aap.2014.eng.6 21. Celfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA. Effect of the 80-hour workweek on resident burnout. Arch Surg 2004;139(9):933-938. https://doi.org/10.1001/archsurg.139.9.933 22. Khoja AT. Evaluation of the educational environment of the Saudi family medicine residency training program. J Fam Community Med 2015;22(1):49‐56. https://doi.org/10.4103/2230-8229.149591 23. Kanashiro J, McAleer S, Roff S. Assessing the educational environment in the operating room – a measure of resident perception at one Canadian institution. Surgery 2006;139(2):150-158. https://doi.org/10.1016/j. surg.2005.07.005 24. Algaidi SA. Assessment of educational environment for interns using Postgraduate Hospital Educational Environment Measure (PHEEM). J T U: Med Sci 2010;5(1):1-12. https://doi.org/10.1016/s1658-3612(10)70118-9

Accepted 22 October 2016.

Research

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

Radiation safety requirements for training of users of diagnostic X-ray equipment in South Africa B van der Merwe,1 PhD; S B Kruger,2 PhD; M M Nel,2 PhD 1

Department of Clinical Sciences, Central University of Technology, Bloemfontein, South Africa

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

Corresponding author: B van der Merwe (bevdmerwe@cut.ac.za)

Background. Globally, the aim of requirements regarding the use and ownership of diagnostic medical X-ray equipment is to limit radiation by abiding by the ‘as low as reasonably achievable’ (ALARA) principle. The ignorance of radiographers with regard to radiation safety requirements, however, is currently a cause of concern. The enhancement of the 4-year radiography curriculum leading to a Bachelor’s qualification provides an opportunity to explore the training and assessment to meet, among others, the ALARA principle, which addresses national and international concerns and criteria. Healthcare workers outside the scope of radiography, who are also considered radiation workers, may be even more ignorant and are therefore also implicated. The process of investigation included a contextualisation of the available regulation documents, the Delphi technique to determine the content of the training, and a questionnaire to test students’ knowledge before and after training. Objectives. To determine the content of the radiation safety requirements training and assessment to implement standardised teaching, learning activities and assessment to prepare radiographers as radiation workers well trained for practice. Methods. The content of the radiation safety requirements training was determined with the Delphi technique. Results. Consensus regarding the content of the radiography students’ training was reached and implemented. Furthermore, it guided the development of teaching and learning activities complemented by aligned assessment. Conclusion. Standardised education and assessment for radiation safety requirements have the potential to ensure that radiation safety regulations are implemented optimally in diagnostic imaging. Afr J Health Professions Educ 2017;9(3):123-127. DOI:10.7196/AJHPE.2017.v9i3.691

The importance of radiation safety training was reiterated by the World Health Organization (WHO). In 2007, World Health Assembly (WHA) Resolution 60.29 urged the WHO to ‘draw up guidelines to ensure the quality, safety and efficacy of medical devices’.[1] Annually, millions of X-ray examinations are done worldwide and, therefore, the benefit/risk balance of every examination should always be considered. The education of radiation workers has the potential to change behaviour to implement a culture of safe patient care. It is important that procedures and requirements are easily understood by health professionals.[1] Not complying with the regulations of safety has often been observed by the principal researcher (BvdM) in clinical practice and is increasingly a matter of great concern. To comply with minimum safety regulation criteria, the entry-level radiography student, placed in clinical practice during the first weeks of training, needs education regarding the safety requirements before being occupationally exposed to radiation. The same applies to radiography students in their 2nd - 4th year, whose safety is the responsibility of the licence holder of medical X-ray equipment. One should also take into consideration that the radiography student may apply to procure X-ray equipment upon graduation, which emphasises the imperative for a training model that will ensure 100% compliance to international standards. Recently, the International Atomic Energy Agency (IAEA) made important international recommendations to promote a safety culture by motivating commitment to protection and safety at all levels. Radiation safety participation must be encouraged and accountability ensured, which implies that a learning attitude should be promoted to carry out tasks safely.[2]

The International Commission on Radiological Protection (ICRP) is the primary body for protection against ionising radiation, created by the 1928 International Congress of Radiology to promote radiological protection as a public interest. The ICRP publishes quarterly recommendations on and guidance in protection against the risks associated with ionising radiation in Annals of the ICRP. Each issue provides in-depth coverage of a specific subject area.[3] The commission has made basic recommendations for education and training of medical staff in ICRP publications 103 and 105.[4] Publication 113 provides guidance regarding the necessary radiological protection education and training for use by regulators, industry and institutions educating professionals involved in radiation in healthcare.[3] In the context of the ICRP publication,[5] the term ‘education’ refers to imparting knowledge and understanding of radiation health effects, regulation, and factors in practice affecting patient and staff doses. It has been suggested that the education should be part of the curriculum of medical, dental, radiography and other healthcare specialists, such as radiologists and medical physicists. The term ‘training’ is defined as coaching with regard to radiological protection for the justified application of modalities (e.g. computed tomography (CT), fluoroscopy) that a healthcare worker uses in medical practice.[5] Having provided an international perspective, it is important to consider the local scenario. The South African (SA) Department of Health (DoH) accepted the recommendations of the ICRP and regulates radiation protection within the framework of the Hazardous Substances Act No. 15

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Research of 1973.[4] This act stipulates that the Minister of Health, and specifically the Director-General of Health, may issue licences to manufacturers, importers and users of electromedical (X-ray) equipment. X-ray equipment comprises electronic products (X-rays) and is considered a Group III hazardous substance. Group III hazardous substances are regulated by Regulation 1332 (regulations concerning the control of electronic products).[6] The SA DoH applies international standards as requirements and guidelines through the Directorate Radiation Control (DRC). The DRC issues a licence if the product and usage comply with the legislative and international requirements for safety and performance.[4] Two documents are effective when a licence is issued, i.e.: (i) ‘Code of practice for users of medical X-ray equipment’;[7] and (ii) ‘Requirements for licence holders with respect to quality-control tests for diagnostic X-ray imaging systems’.[8] The requirements in these two documents were contextualised as criteria in the Delphi document to determine the content of the training for radio graphy students. It is important that radiographers as radiation workers and users of X-ray equipment are aware of the legislation and regulations underpinning the use of the equipment. They must therefore be informed that the documents exist and consequently be educated in the regulations before applying them.

Standardised training of radiation safety regulations in SA

The responsibilities of licence holders of medical X-ray equipment are listed in the ‘Code of practice for users of medical X-ray equipment’.[7] Apart from equipment requirements, the licence holder and responsible person must ensure that those who are occupationally exposed to ionising radiation (radiation workers) are identified and issued with personal radiation monitoring devices (PRMDs). Diagnostic radiographers employed in radiography departments and radiography students in training, who are occupationally exposed to radiation, are therefore radiation workers.[4] The code further mandates that every radiation worker receives ‘education regarding the risks and safety rules of ionising radiation; that protective clothing, devices and equipment are provided and properly used; radiation safety rules are communicated to and followed by all personnel; operational procedures are established and maintained to ensure that the radiation exposure to workers, patients and public is kept [as low as reasonably achievable] ALARA without compromising the diagnostic efficiency of the result; and lastly, that workers are educated in the hazards and risks of ionising radiation’.[7] Entry-level radiation workers, e.g. 1st-year radiography students, are legally required to be monitored and issued with PRMDs (commonly referred to as dosimeters) as soon as they are placed in clinical practice. No standardised monitoring of the required education is currently in place. The dosimeter can be ordered from the Radiation Protection Service (RPS) of the SA Bureau of Standards (SABS). The only DRC requirement before registration as a radiation worker and subsequent issuing of the dosimeter, is that a new radiation worker must undergo a medical examination to determine fitness to work.[7] This implies that a licence holder may order dosimeters without submitting proof of education of radiation workers regarding ionising radiation safety. The concern is that the responsibility of the training institution is not signified, which may be the reason for the lack of vigilance observed in clinical practice in terms of the application of certain radiation safety principles. Radiography training institutions have different policies regarding the training and issuing of dosimeters to 1st-year radiography students. As a

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rule, the department in which the student is placed for clinical practice is responsible to register the radiation worker and order the dosimeters. The status quo at one training institution may be that the clinical department issues the dosimeters, while the training institution in due course incorporates the radiation safety lectures combined with a radiation protection test. In another setting, dosimeters may be issued within the first week of clinical practice, only to lecture on the academic aspects of dosimeters and radiation risks over the course of a year. These varying procedures result in an unfavourable situation, where the training institution places the radiation safety responsibility of the radiation worker solely on the hospital or practice where the 1st-year student is assigned to for workplace learning. The education of these members of staff regarding radiation is not formally monitored in most hospitals.[9] The researcher observed ignorance regarding the wearing of dosimeters, confirming that human error must be considered.[10] The responsibilities of licence holders of X-ray equipment are further outlined in the ‘Requirements for licence holders with respect to qualitycontrol tests for diagnostic X-ray imaging systems’.[8] This document emphasises the acceptance and quality-control tests of diagnostic X-ray equipment. Since 31 March 2009, an inspection body, approved by the DoH or an appropriately trained professional registered with the Health Professions Council of South Africa (HPCSA) as a medical physicist, must perform all the acceptance and routine tests. Radiographers, however, are responsible for the routine tests; it is important that they are not only familiar with the requirements, but also equipped to perform thse tests, interpret the tests and adjust necessary parameters to maintain safety on a daily basis. The training must therefore include quality testing of X-ray equipment. The Central University of Technology (CUT) in Bloemfontein, SA, had the privilege to engage in a curriculum review process that led to CUT being one of the first training institutions for radiography in the country to implement a 4-year qualification in radiography in 2014. The curriculum development process provided an opportunity to determine appropriate content for the radiation safety and quality-control requirements training module. By using the Delphi technique, content was confirmed for basic outcomes for 1st-year radiography students (representing the entry-level radiation worker issued with a dosimeter), and advanced outcomes for 3rdyear radiography students (representing the licence holder, responsible person and qualified radiographer). The development of teaching and learning activities and assessment strategies for radiography radiation safety based on the findings of the Delphi survey will be reported in separate publications.

The Delphi technique

In this study, the Delphi technique was used to reach consensus[11] on the content of the radiation safety regulations training course. The technique differs from other methods of gathering data from a group of people, as it involves a research team, who are involved collectively with the goal of enhancing the quality and utilisation of the research.[11] The Delphi technique is a decision-making process that has been used for planning and collective decision-making, not only in the field of technology, but also in healthcare and education.[12] In the decision to use the Delphi technique, we took cognisance of two inferences, i.e. that decisions are more valid if the judgement of a group of people is involved, and the possibility that the group members may be influenced by one another if decisionmaking occurs in the presence of the group.[13] A study by Skulmoski et al.[14] indicates that because of the flexibility of the Delphi process, the method may be adapted creatively for most studies. Their study provides proof of numerous three-round studies with successful

Research effects. The current study, however, required four rounds. In the fourth round, the panellists were informed that if they wished they could change their opinion. Stability in this study was declared when participants did not change the selection in more than one round.[15] The Delphi technique was used in this study to establish a set of criteria needed for the development and implementation of a training course for diagnostic radiography students. The process involved a quantitative approach that was appropriate for determining the objectives for the radiation safety training course. On the Delphi questionnaire the participants had to respond by making choices between various statements; they were granted opportunities to add comments or suggestions. The latter gave the panellists an opportunity for inductive reasoning and to make unique contributions.[16] The questionnaire encouraged expression of the expert opinion of the panellists by indicating in the information document that the responses would be incorporated in follow-up rounds. The controlled anonymous feedback is a positive characteristic of the process, rendering it suitable to receive feedback from individuals who are physically separated.[17]

Method

Data collection entailed a Delphi process that was mainly quantitative, with an invitation to panellists to add comments or suggestions. The qualitative findings were reported by incorporating the comments in the follow-up rounds of the Delphi process. The research was aimed at improving the current practice of radiation safety training of radiographers and was, therefore, considered action research.[18] The processes of action and research was integrated because the teaching activities and assessment were developed after the Delphi survey and aligned with the criteria accepted through the Delphi process.[18]

Participants in the Delphi questionnaire

The 10 participants in the Delphi questionnaire were experts in the field of diagnostic imaging. The panel included lecturers at higher education institutions involved in radiography training, medical physicists involved in quality tests in diagnostic departments, diagnostic radiography managers of radiography departments and the DRC. The researcher selected the Delphi participants based on the expected value they would add to the study.[18] The sample consisted of 10 individuals from several institutions that consented to participate in the Delphi process, including male and female participants considered knowledgeable in the code of practice for users of medical X-ray equipment and the DoH requirements for licence holders of diagnostic imaging systems. The lecturers were involved in the modules pertaining to radiation protection, and the radiography managers were involved in quality control of medical imaging systems.

Ethical approval

Ethical approval for this project (ref. no. ECUFS 74/2013) was obtained from the Ethics Committee, Faculty of Health Sciences, University of the Free State (UFS). The Delphi procedure was commenced with an invitation letter regarding the purpose of the study, the process and the duration of the study; the participants gave written consent upon receipt of the invitation.[18] Each participant’s response was colour coded to reflect anonymity.

Compilation of the Delphi questionnaire

The SA DoH requirement statements for licence holders of medical X-ray equipment, contained in the ‘Code of practice for users of medical X-ray

equipment’[7] and ‘Requirements for licence holders with respect to qualitycontrol tests for diagnostic X-ray imaging systems’[8] were presented as 418 criteria in the Delphi questionnaire. Each statement had to be evaluated for inclusion in a basic training course before dosimeters could be issued to the beginner radiation worker, or the advanced training course for the potential licence holder of X-ray equipment. The options were stated on a 4-point Likert scale. These points were defined as follows: 1 = both courses; 2 = basic only; 3 = advanced only; and 4 = none. The layout of the questionnaire was divided into the following sections: 1. General definitions and licensing conditions (n=84) 2. Responsibilities of licence holders/responsible person (n=18) 3. Operators of equipment and radiation workers (n=38) 4. Radiation protection of patients (n=81) 5. Radiation protection for the radiation worker (n=77) 6. Quality-control tests for diagnostic medical systems (n=94) 7. The training course (n=26). Space was provided for comments for each specific statement and at the end of the section for additional comments deemed necessary by the panellists. Section 1. General definitions and licensing conditions This section dealt with the requirements and recommendation documents for radiation safety associated with the use of medical diagnostic X-ray equipment. It also dealt with the licensing conditions for medical X-ray equipment, with specific reference to the requirements of the apparatus for diagnostic use. The adherence to specific conditions for premises of X-ray equipment was stated in detail. This section was divided into three subsections, each containing various statements (n=84). Section 2. Responsibilities of licence holders/responsible person This section dealt with the responsibilities of licence holders or appointed responsible persons. It contained various statements (n=18). Section 3. Operators of equipment and radiation workers This section dealt with the operators of diagnostic X-ray equipment, with specifics on the application and monitoring aspects of radiation workers. The issuing of the personal monitoring device with the detailed threshold dose limits for radiation workers received attention in this section. It was divided into two subsections, each containing various statements (n=38). Section 4. Radiation protection of patients This section dealt with the basic radiation principles for the public. The importance of justification, optimisation and limitation in managing ionising radiation was stated in order to adhere to the ALARA principle. This section was divided into four subsections, each containing various statements (n=81). The statements referred to general radiography, fluoroscopy and CT. Section 5. Radiation protection for the radiation worker This section dealt with the basic radiation principles and personal monitoring devices for the worker. The statements dealt with the identification and application of principles and techniques to lower the radiation dose to staff in the healthcare environment. The care of the monitoring device with regard to optimal use was also specifically stated. This section was divided into two subsections, each containing various statements (n=77).

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Research Section 6. Quality-control tests for diagnostic medical systems This section dealt with the requirements for licence holders with regard to quality-control tests for diagnostic imaging systems. The recording, interpretation and management of the results of the tests received meticulous focus. The frequencies of the tests were listed for diagnostic, CT and mammography equipment. This section was divided into four subsections, each containing various statements (n=94). Section 7. The training course* This section dealt with the training course presentation and assessment. The statements dealt with the learning and teaching activities for the basic and advanced courses in terms of the presentation, either online or in a classroom setting. This section contained various statements (n=26). The percentage of participants making a specific choice on the Likert scale is indicated as selecting either ‘Strongly agree’, ‘Agree’, ‘Disagree’ or ‘Strongly disagree’; e.g. 1 = 80%; 2 = 0%; 3 = 20%; 4 = 0%, with 1, 2, 3 and 4 referring to the respective terms on the scale in the order mentioned above.

Results

The researcher manually prepared the analysis of the various rounds of the Delphi process. The researcher also entered all quantitative responses in Microsoft Excel (USA) for calculation of consensus and stability and the development of the questions for the next round. The qualitative data were categorised into themes to make an identifying summary. These common themes were added in the next round as additional criteria items. The new items were incorporated in the following round and communicated as such to the panellists. Every round served to refine the results of the previous rounds.[11] A response rate of 100% was obtained in all four rounds of the Delphi process. Consensus was reached when 80% of the panellists agreed on a certain criterion.[19] Consensus was reached on 309/418 (74%) statements in the questionnaire. Among the 418 statements, consensus was reached on 13 selections for both basic and advanced training and assessment, 131 selections for basic training and assessment, and 137 selections for advanced training and assessment, with no exclusion of any statements from the training and assessment. Stability was determined on completion of the fourth round. Linstone and Turoff[15] describe stability as the tendency of expert opinions to merge when there is stability in the movement of the group’s responses. Stability, which may be declared when movement of opinion of the group as a whole has reached stability, was acquired with regard to the remaining 26% of statements.

Discussion and recommendations

The relatively high degree of consensus and stability, combined with no statements being excluded from the training and assessment by a diverse group of panellists, support the appropriateness of the conclusions drawn from these data. The comments from the Delphi panellists regarding the content of radiation safety and assessment provided insight that guided the researcher to consider important aspects, e.g. the basic training must address the awareness of principles, and the advanced training must engage the student in more in-depth training. Section 7 of the Delphi questionnaire dealt with the presentation of the training and the panellists’ opinions on the assessment of radiation safety. The panellists strongly agreed that all the criteria on which consensus was reached in the survey had to be included in both the basic and advanced assessment. They also agreed that the Delphi questionnaire covered all the aspects required to use diagnostic X-ray

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equipment safely, with the comment that it was comprehensive without the guarantee of completeness. The panellists strongly agreed that successful completion of the basic and advanced training should be confirmed by assessment, and that the score to indicate successful completion of both assessments should be a minimum of 75%. The panel disagreed that distance learning was appropriate for basic training, as students need hands-on training. The panel did not reach consensus on the appropriateness of distance learning for advanced training. They disagreed that the student would master the content of the training by self-learning and added specifically that there was a need to execute the tests, and that evidence should be recorded for the advanced students. The panellists strongly agreed that content on risks of radiation and interaction of radiation and tissue had to be included in the basic training. Further comments from the panellists included that insight in the workload should be evenly distributed between the training, and that the advanced training should build on criteria for the basic training. The information contained in the training was regarded as necessary for different reasons, including professional, clinical, or compliance. Repetition of the content, according to the panellists, would ensure a high degree of understanding and recollection. Information was allocated to the basic training, which the students could use immediately, but information on technical equipment and structural specifications was recommended for the advanced training. The concluding comments addressed the need for supervision and monitoring for both trainings to ensure that correct quality tests were carried out and that candidates gained understanding of acceptable limits of the tests. Flexibility was reiterated in terms of the offering and assessment owing to the reality of scarce resources in SA. The comments from the panellists provided insight in and guidance for the final list of criteria to be included in either the basic or advanced training and assessment. The comments were incorporated in the teaching and learning activities.

Conclusion

By involving a panel of experts to determine the content of radiation safety training and the criteria and methods for assessment, the study can make a contribution to the existing body of knowledge in the field of radiography. Furthermore, the training programme has already been found to deliver a better-trained 1st-year student to the radiography profession and practice. To equip the radiation worker with standardised knowledge and expect from the student to provide standardised evidence of mastery of radiation safety principles and requirements, is a major step to optimally apply the currently neglected ALARA principle in practice. *Supplementary information. An appendix is available from the corresponding author on request. Acknowledgements. The authors wish to thank the Health and Welfare Sector Education and Training Authority (HWSETA) for funding, Prof. Driekie HaySwemmer for assistance with the preparation of the article, and Dr Daleen Struwig for final technical and editorial preparation of the manuscript. Author contributions. BvdM was responsible for the literature search, conceptualisation, design of the training and assessment, and drafting of the manuscript. SK, as the study leader, and MMN, as the co-study leader, revised the manuscript critically. All three authors approved the final version of the manuscript submitted for publication. Funding. Funding was provided by HWSETA. Conflicts of interest. None.

Research 1. Perez M. Enhancing radiation safety and quality in healthcare. Proceedings of the 18th ISRRT World Congress, 12 - 15 June 2014, Helsinki, Finland. http://portfolio-web.ess.fi/www/SuomenRontgenhoitajat/2014_ISRRT/#/1/ (accessed 23 June 2017). 2. International Atomic Energy Agency. Radiation protection and safety of radiation sources: International basic safety standards. IAEA Safety Standards Series GSR Part 3. Vienna: IAEA, 2014. http://www-pub.iaea.org/books/ IAEABooks/8930/Radiation-Protection-and-Safety-of-Radiation-Sources-International-Basic-Safety-Standards (accessed 23 June 2017). 3. VaĂąo E, Rosenstein M, Liniecki J, Rehani M, Martin CJ, Vetter RJ. Education and training in radiological protection for diagnostic and interventional procedures. ICRP Publication 113. Ann ICRP 2009; 39(5). http:// www.icrp.org/publication.asp?id=ICRP%20Publication%20113 (accessed 20 June 2017). 4. South African Government. Hazardous Substances Act, 1973 (Act No. 15 of 1973). Government Gazette No. 3834:550. 1973. 5. International Commission on Radiological Protection. The 2007 recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann ICRP 2007;37(2-4). 6. South Africa. Regulations: Control of electronic products. Government Gazette No. 3991, 1973. (Published under Government Notice R1332.) https://docs.google.com/file/d/0B5d_I5LlOhwTYzZjY2I1ZDEtOWQwMy00YjU5LTg1ZDQtNzNmMTkzNzdkZjU4/edit?pli=1 (accessed 20 June 2017). 7. Department of Health. Directorate: Radiation control. Code of practice for users of medical X-ray equipment. 2011. http://www.scribd.com/doc/33826566/Department-of-Health#scribd (accessed 23 June 2017). 8. Department of Health. Directorate: Radiation Control. Requirements for licence holders with respect to quality control tests for diagnostic X-ray imaging systems. 2012. http://rssa.co.za/alerts/department-of-healthdiagnostic-quality-control.html (accessed 23 June 2017).

9. Van der Merwe B. Radiation distribution in a private neurological theatre during invasive back pain management procedures. MHPE. Bloemfontein: Central University of Technology, 2008. 10. Herbst CP, Fick GH. Radiation protection and the safe use of X-ray equipment: Laws, regulations and responsibilities. S Afr J Radiol 2012;16(2):50-54. https://doi.org/10.4102/sajr.v16i2.306 11. Du Plessis E, Human S. The art of the Delphi technique: Highlighting its scientific merit. Health SA Gesondheid 2007;12(4):13-24. https://doi.org/10.4102/hsag.v12i4.268 12. Loo R. The Delphi method: A powerful tool for strategic management. Policing. Int J Police Strat Manage 2002;25(4):762-769. https://doi.org/10.1108/13639510210450677 13. Murray JW Jr, Hammons JO. Delphi: A versatile methodology for conducting qualitative research. Rev Higher Educ 1995;18(4):423-436. https://doi.org/10.1353/rhe.1995.0008 14. Skulmoski GJ, Hartman FT, Krahn J. The Delphi method for graduate research. J Inform Technol Educ 2007;6:1-21. 15. Linstone HA, Turoff M. The Delphi Method: Technique and Application. London: Addison-Wesley, 1979. 16. Cottrell RR, McKenzie JF. Health Promotion and Education Research Methods. Sudbury: Jones and Bartlett, 2011. 17. Nel CPG. A framework for achieving excellence as a clinical educator in the School of Medicine, University of the Free State. MHPE. Bloemfontein, University of the Free State, 2007. 18. Denscombe M. The Good Research Guide. 3rd ed. Maidenhead, UK: Open University Press, 2007. 19. Larson E, Wissman J. Critical academic skills for Kansas Community College graduates: A Delphi study. Commun Coll Rev 2000;28(2):43-56. https://doi.org/10.1177/009155210002800203

Accepted 21 February 2017.

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Research

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

Training requirements for the administration of intravenous contrast media by radiographers: Radiologists’ perspective G G V Koch,1 MHSc: Radiography (D); L D Swindon,1 MEd (HE), BTech: Radiography (D); J D Pillay,2 PhD (Physiology) 1

Department of Radiography, Faculty of Health Sciences, Durban University of Technology, South Africa

Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, South Africa

Corresponding author: G G V Koch (erhardkoch9@gmail.com)

Background. The administration of intravenous contrast media (IVCM) is one of the key areas currently under investigation for inclusion in the South African (SA) radiographers’ scope of practice. However, for the radiographers to legally administer IVCM, training guidelines must first be identified, developed and accredited by the Health Professions Council of SA. Objective. To investigate the radiologists’ perspective of the knowledge, skills and medicolegal training required of radiographers for the administration of IVCM to provide input for the development of national training guidelines. Methods. A quantitative, cross-sectional research study using an online survey, administered by SurveyMonkey, was conducted. The target population included all radiologists residing and practising in the province of KwaZulu-Natal, SA. Results. Fifty-nine participants (60.8%) completed the online survey. Twelve were excluded owing to incomplete surveys, resulting in a final response rate of 48.5% (n=47). The study revealed that various theoretical, clinical/practical and medicolegal study units should be included in the training, i.e. the study of the pharmacology of contrast media, practical training on cardiopulmonary resuscitation and basic life support, as well as the rights and responsibilities of a healthcare professional. In addition, both theory and practical/clinical assessments need to be included. Conclusion. Key data have been provided for the development of national training guidelines for radiographers to administer IVCM, based on scientific evidence that is relevant to the SA context. The study may be of value to other related health professions where scopes of practice are expanded through transforming the education and training curricula. Afr J Health Professions Educ 2017;9(3):128-132. DOI:10.7196/AJHPE.2017.v9i3.809

The healthcare system is driven by rapidly advancing technologies and international trends. In view of this, healthcare needs are constantly evolving. To meet these needs, the scope of practice of healthcare professionals requires regular re-evaluation. This is achieved through transforming higher education (HE) and training and obtaining approval and accreditation from the relevant professional boards. It is important that the input for transforming HE and training and expanding the scope of practice is based on scientific evidence that has been obtained through local research. This is necessary for HE and training to be contextualised, while remaining aligned with international trends. Radiography is a vital component in the medical field; however, the roles and responsibilities of radiographers and radiologists are often misunderstood. Radiologists are medical physicians specialised in radio logy and responsible for diagnosing and managing patients, whereas radiographers are healthcare professionals responsible for producing the medical images needed by radiologists to make an accurate diagnosis.[1] Although radiographers and radiologists work in close collaboration, their roles, responsibilities and professional scopes of practice are different, and are determined by the scope of their relevant professions and training.[2] Radiographers, globally, have significantly different scopes of practice. In Ireland, Canada and Europe they are permitted to administer intravenous contrast media (IVCM) after having completed advanced training.[3-5] IVCM can be defined as imaging agents administered to a patient during specialised radiographic investigations to enhance the visibility of the

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internal anatomical structures.[6] Radiographers practising in the USA may also administer IVCM after certification by either the American Registry of Radiologic Technologists (ARRT) or the American Registry of Magnetic Resonance Imaging Technologists (ARMRIT).[7] Similarly, radiographers in the UK are able to advance to the levels of ‘consultant’ and ‘advanced practice’ radiographers.[8,9] The scopes of radiographers in these countries are defined by their training, which may differ between countries. Radiographers in South Africa (SA) have been found to perform, illegally, the task of IVCM administration, which currently falls within the scope of radiologists.[10] This practice may be motivated by the national shortage of radiologists and subsequent service delivery constraints.[11,12] In SA, the radiologist-to-patient ratio is in the region of 1:57 937.[11] Radiographers in SA are not legally permitted to administer IVCM, as no formal Health Professions Council of SA (HPCSA)-accredited training is currently offered.[13] They are, therefore, performing a criminal act and may be penalised accordingly. Radiologists in SA have agreed in principle with the idea of having the radiographers’ professional scope of practice expanded to include the administration of IVCM, provided the necessary further training is formalised and undertaken.[14] As the administration of IVCM currently falls within the legal scope of practice of radiologists, it is logical that radiologists would be able to provide valuable information in this regard. Possible advantages of role extension may include an improvement in the delivery of radiology services and the alignment of radiography with international standards.[10]

Research The Professional Board for Radiography and Clinical Technology (PBRCT) is currently addressing role extension for radiographers, and research studies conducted locally have identified the need for the further training of radiographers to administer IVCM.[10,12] Our research study, therefore, hopes to provide input for the HPCSA for the development of national training guidelines that are based on local scientific evidence.

Data analysis

Methods

Results

A quantitative, cross-sectional survey was conducted in the province of KwaZulu-Natal (KZN), SA. The study was limited to radiologists who were registered with the HPCSA and who were practising and residing in KZN. The target population was identified by means of the HPCSA’s online register, which is available to the public. In addition, the researcher identified participants by word of mouth and social media, i.e. Facebook and LinkedIn. The HPCSA register listed a total of 104 radiologists and, using a confidence level of 95%, it was found that a minimum of 87 responses were needed. However, the exact number of radiologists living and/or practising in KZN could not be determined, as some members who appear ‘active’ on the register could be deceased or have relocated. Therefore, as the total population was unknown, a 60% response rate was deemed to be statistically acceptable.

Agreement on knowledge components

Research design and study participants

Sampling

A purposive (non-probability) sampling technique was used, which was selected to provide input on a distinct research topic, the administration of IVCM by radiographers. The total target population was used in an attempt to obtain the minimum response rate.

Ethical considerations

Ethical clearance for the study was obtained from the Institutional Research and Ethics Committee, Durban University of Technology (ref. no. REC 18/15). A letter of information was included in the email communication sent to the participants, providing them with an outline of the research study and stating that the results may be published in a suitable journal. Consent was assumed when participants completed the survey. No identifiable details were requested from the participants, thus ensuring confidentiality and anonymity. The participants were free to exit the survey at any time.

Research tool and data collection

An online survey administered by SurveyMonkey was used to collect data. The participants were emailed a web link for the survey and a request for participation. The survey included questions and statements relating to the knowledge, skills and medicolegal training required by radiographers to administer IVCM. The content of the survey was benchmarked against international practice standards and training requirements of the radiography profession. The questions and statements in the survey were reviewed by a focus group prior to the data collection process to ensure validity and reliability. The structure of the survey was altered to follow the practical sequence of contrast media administration, i.e. placement of aspects related to patient preparation before those related to administration of the contrast media. The focus group consisted of the authors, a radiologist and two radiographers. They were selected based on their experience in the field of this research study.

The data obtained from this research study were analysed using the Statistical Package for the Social Sciences (SPSS), version 23.0 (IBM Corp., USA). Descriptive and inferential statistics were applied. Factor analysis and reliability testing using Cronbach’s alpha were included. Statistical significance was set at p<0.05.

Fifty-nine participants (60.8%) completed the online survey. Twelve were excluded owing to incomplete surveys, resulting in a final response rate of 48.5% (n=47). The majority of respondents were practising in the private sector (68.1%), 98.0% had been qualified as radiologists between 0 and 29 years, the majority were males (78.7%) and more than half (51.1%) were between 40 and 49 years of age.

Table 1 provides the level of agreement (represented as a percentage) among the respondents for the inclusion of the anatomy, physiology and pathology of the cardiovascular, urinary and nervous system and the upper and lower limbs. The level of agreement was significantly high among the respondents with regard to the inclusion of basic anatomy, physiology and pathology of the cardiovascular, urinary and nervous system and the upper and lower limbs. However, the level of agreement for including the physiology component of the upper and lower limbs was lower compared with that for the inclusion of anatomy and pathology. Although the respiratory system was not included in the survey, the study respondents identified it as being necessary for inclusion in the further training. The respiratory system was considered important, based on the possibility of complications and adverse reactions occurring owing to the administration of IVCM. Therefore, it is necessary to be able to recognise the signs and symptoms associated with respiratory distress. Table 2 provides information based on the need for further training in areas/systems related to contrast media and possible reactions. The level of agreement related to the knowledge components of contrast media and possible reactions was >85% in all instances. The results, therefore, suggest that these components are essential for inclusion in the training requirements for radiographers to administer IVCM. In addition to the results presented in Table 2, the theory of cardiopulmonary resuscitation (CPR) and basic life support (BLS) was considered important for further training, with agreement levels of 95.74% and 100.00%, respectively. The study of the pharmacology of emergency medicines and the administration thereof, however, indicated lower levels of agreement (68.09% and 65.96%, respectively). The majority of respondents (87.20%) were of the opinion that a theoretical assessment should be conducted towards the end of the training and should contribute a minimum weighting of 0.25 towards the final mark.

Agreement on skills components

Fig. 1 presents information pertaining to the technique/s for administering IVCM. All the skills components demonstrate a high level of agreement (95%), apart from the component related to observations of IVCM administration, which indicated an average level of agreement of 85%. Notwithstanding this, the results demonstrate high levels of agreement among the majority of

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Research Table 1. Level of agreement on knowledge components in anatomy, physiology and pathology

Table 2. Level of agreement on knowledge components in contrast media and possible reactions

Neutral, %

Agree, %

Cardiovascular system

Basic Advanced

2.13 38.30

0.00 42.55

97.87 19.15

Urinary system

Basic Advanced

6.38 36.17

6.38 34.04

87.23 29.79

Nervous system

Basic Advanced

10.64 48.94

2.13 29.79

87.23 21.3

Upper limb

Basic Advanced

4.26 25.53

2.13 38.30

93.62 36.17

Lower limb

Basic Advanced

4.26 31.91

4.26 44.68

91.49 23.40

Cardiovascular system

Basic Advanced

4.26 44.68

17.02 44.68

78.72 10.64

Urinary system

Basic Advanced

8.51 46.81

12.77 38.30

78.72 14.89

Nervous system

Basic Advanced

10.64 53.19

19.15 38.30

70.21 8.51

Upper limb

Basic Advanced

12.77 53.19

21.28 38.30

65.96 8.51

Basic Advanced

12.77 53.19

25.53 42.55

61.70 4.26

Cardiovascular system

Basic Advanced

6.38 53.19

10.64 42.55

82.98 4.26

Urinary system

Basic Advanced

8.51 48.94

6.38 36.17

85.11 14.89

Nervous system

Basic Advanced

8.51 53.19

4.26 34.04

87.23 12.77

Upper limb

Basic Advanced

6.38 55.32

10.64 34.04

82.98 10.64

Basic Advanced

6.38 57.45

10.64 38.30

82.98 4.26

Anatomy

Physiology

Lower limb

respondents with regard to the observation of needle placement and IVCM administration, as well as the unassisted practice of these two skills. The respondents further agreed that a minimum of 10 needle placements be observed and a minimum of 20 unassisted, independent needle placements should be recorded. It is felt that the radiographers should observe a minimum of 20 IVCM administrations and also record a minimum of 20 unÂassisted, independent IVCM administrations. There is agreement that the radiographer should seek assistance after two failed attempts at placing the needle. Fig. 2 presents information pertaining to the clinical/practical components for inclusion in the further training of radiographers to administer IVCM. Patient preparation, management and aftercare, infection control, and CPR and BLS practical training were agreed upon by the majority of respondents for inclusion in the further training of radiographers to administer IVCM. More than 55% of the respondents felt that practical training regarding the administration of emergency medicines and record

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Neutral, %

Agree, %

Pharmacology

2.13

95.74

Preparation

4.26

91.49

Type and dose administered for the adult and paediatric patient

0.00

2.13

97.87

Clinical/biomedical indications and contraindications

0.00

2.13

97.87

Types of needles and accessories

0.00

2.13

97.87

Techniques for needle placement

0.00

10.64

89.36

Methods of maintaining intravenous access

0.00

2.13

97.87

Infection control

0.00

4.26

95.74

Complications and adverse reactions

0.00

100.00

Treatment of complications and adverse reactions

0.00

8.51

91.49

95.74

93.62

85.11

Disagree

Neutral Agree

12.77 2.13 4.26

2.13 2.13

6.38

2.13

ne Ob ed ser le va pl tio ac n em of en ts ne Un ed na s le si pl ste ac d em IV en ts Ob se ad r v m at in ion ist s ra IV tio CM ns

Pathology

Disagree, %

100

Level of agreement, %

Lower limb

Study unit

0.00

2.13 4.26

Se ek a f as ai sis le ta d n at ce te a m fte pt r

Disagree, %

Un ad ass m ist in ed ist I ra VC tio M ns

Level

Component

Skills component

Fig. 1. Technique/s. (IV = intravenous; IVCM = intravenous contrast media.)

keeping of observational hours of IVCM administrations (40 hours) should be included in the further training. It is noted, however, that of all the clinical/practical components presented in Fig. 2, practical training regarding the administration of emergency medicines received the highest level of disagreement (12.77%). The majority of respondents (93.6%) were of the opinion that a clinical assessment be conducted towards the end of the training, which should contribute a minimum weighting of 0.25 towards the final mark. In addition, the results reveal that the students should keep a record of clinical competencies, which should be used as an assessment, with a minimum weighting of 0.25 towards the final mark.

Agreement on medicolegal components

Table 3 provides information based on the medicolegal study units to be included as part of the further training for radiographers to administer IVCM. High levels of agreement (>80%) were indicated for the study of basic patient rights and ethics, the rights and responsibilities of a

Research Table 3. Level of agreement on medicolegal study units Study unit

Level

Disagree, %

Neutral, %

Agree, %

Medical law

Basic Advanced

12.77 70.21

36.17 27.66

51.06 2.13

Patient rights and ethics

Basic Advanced

2.13 46.81

12.77 44.68

85.11 8.51

Rights and responsibilities of a healthcare professional

2.13

14.89

82.89

Designing medical policies and procedural protocols

10.64

44.68

Quality assurance

0.00

12.77

87.23

Cultural diversity

4.26

40.43

55.32

Patient management and communication

2.13

10.64

87.23

100 93.62

91.49

93.62

95.74

Disagree Neutral Agree

Level of agreement, %

63.83 59.57

40 34.04 27.66 20 12.77 6.38 2.13

0.00

4.26 2.13

2.13 2.13

2.13

Pr m ope an r ag pa em tie en nt p t a re nd pa af rat te io m rc n, ea Inf ar su ec e re tio sa n nd co pr ntr Pr ec ol ac au tic tio al ns tra in in g on Pr ac CP tic of Prac R al em tic t ra er al t i ni ge ra n o g ho f a ncy inin on ur re m g o BL s o co ed n S f I rd ici th VC of ne e a M ob s a dm ad se nd in m rv t i Re ini atio he stra co str n ke tio at al ep n rd in of ion g ob s se rv at io na lh ou rs

6.38

Skills component

Fig. 2. Clinical/practical component. (CPR = cardiopulmonary resuscitation; BLS = basic life support; IVCM = intravenous contrast media.)

healthcare professional, quality assurance, and patient management and communication. In contrast, the study of basic medical law, designing medical policies and procedural protocols, and cultural diversity collectively received lower levels of agreement (Ë&#x201A;60%) and higher levels of neutrality (>35%), indicating that these were possibly not critical areas for training.

Discussion

Trends in HE and training, coupled with the changing needs of healthcare service delivery, are well documented. The integration of HE and training with the professional needs of the radiography profession is of vital importance, as the profession is changing and expanding globally.[15] It is important to investigate, compare and reflect on the training that other countries have in place so that the quality of the training guidelines for health professionals in SA can be improved through benchmarking, while still maintaining a local context. The need for scientific (local)

research to be conducted, is deemed particularly important for addressing the specific healthcare needs of SA. The level and duration of the training of SA radiographers can only be established once the national training guidelines have been identified and approved by the PBRCT. Only then can educational institutions offer training that extends the scope of practice and raises the status of the profession. This research study revealed that both a theoretical and skills component of training should be included for radiographers to administer IVCM. This is similar to the training offered in southern Europe at the University of Malta and in the UK.[5,16] For example, the theoretical components offered at the University of Malta and in the UK include the study of the anatomy of the upper and lower limbs, general physiology, contrast media, patient parameters (e.g. blood pressure), emergency medicines and equipment, infection control, technique associated with needle placements and IVCM administrations, as well as the study of medicolegal issues and legislation.[5,16] With regard to the skills component, the training offered at the University of Malta requires that radiographers need to observe a minimum of five IVCM administrations and to record a minimum of 50 unassisted, independent IVCM administrations. The radiographers are also expected to seek assistance after two failed attempts at placing the needle.[5] The results from this research study revealed a similar pattern regarding the minimum number of failed attempts at placing the needle; however, there is agreement regarding the minimum number of 20 unassisted, independent IVCM administrations included in the training guidelines for UK radiographers.[16] International training standards state that the practical CPR training must be updated annually.[5,17,18] The competency profile for further training issued by the Ontario Association of Medical Radiation Sciences (OAMRS) in Canada, recommends that in addition to this, an annual clinical competency assessment should be conducted.[18] This, however, requires further investigation, as the research tool for our study did not include the relevant questions. With regard to medicolegal training, the results are in favour of the study units included internationally. Both theoretical and clinical assessments are conducted internationally and are in line with the recommendations of this study. Our study indicated that the assessments should contribute a minimum weighting of 0.25 towards the final mark. The weightings of the assessments internationally, however, are different. The theoretical assessment at the University of Malta contributes a weighting of 0.60 towards the final mark and the remaining weighting of 0.40 is calculated from clinical practice, which includes a record of clinical competencies.[5]

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Research Summary of recommendations with regard to training guidelines

The findings of this study highlight the need for theoretical, clinical/practical and medicolegal elements forming essential components of training, and the assessment thereof.

Theoretical components

• Basic anatomy, physiology and pathology of the cardiovascular, urinary, nervous and respiratory system and of the upper and lower limbs. • The preparation and pharmacology of IVCM, as well as clinical and biomedical indications and contraindications. • Infection control, the different types of needles and accessories, as well as the technique/s for placing the needle and how to maintain IV access. • The different types and dose of IVCM administered for adult and paed iatric patients. • The possible complications of and adverse reactions to IVCM and the treatment/management thereof. • CPR, BLS, the pharmacology of emergency medicines and drugs, as well as the administration thereof.

Clinical/practical components

• Observation of 10 needle placements and a record of 20 unassisted, indepen dent needle placements. • Observation of 20 IVCM administrations and a record 20 unassisted, indepen dent IVCM administrations. • Patient preparation, management and after-care, as well as practical training regarding infection control, CPR and BLS. • Practical training on the administration of emergency medicines and drugs. • Observation of 40 hours of studies involving contrast media.

Medicolegal components

• The study of basic medical law, basic patient rights and ethics, as well as the rights and responsibilities of a healthcare professional. • Quality assurance, cultural diversity, patient management and communi cation.

Assessments

• A theoretical assessment, contributing a minimum weighting of 0.25 towards the final course mark. • A clinical assessment, contributing a minimum weighting of 0.25 towards the final course mark. • A record of clinical competencies, contributing a minimum weighting of 0.25 towards the final course mark.

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Conclusion

The study, in providing key data for the development of training guidelines for radiographers to administer IVCM, demonstrates the importance of HE and training in addressing transformation in health services, with particular reference to the professional scope of practice. Furthermore, it reinforces the need for local research that will inform HE and training and hence a scope of practice that meets local needs. Acknowledgements. The author would like to thank the co-authors for their guidance while writing this article, and the study participants for their input. Author contributions. GGVK, LDS: contributed substantially towards the conceptualisation of this study. GGVK, LDS, JDP: contributed towards the design, analysis and interpretation of data, as well as the final approval of the article. Funding. Financial assistance was received from the Faculty of Health Sciences, Durban University of Technology. Conflicts of interest. None. 1. O’Sullivan B, Goergen S. X-ray. 2009. http://www.focusradiology.com.au/services/x-ray/ (accessed 13 August 2017). 2. Etheredge HR. An opinion on radiography, ethics and the law in South Africa. S Afr Radiographer 2011;49(1):9-12. 3. The Irish Institute of Radiography and Radiation Therapy. Intravenous Administration by Radiographers – Guidelines on Best Practice. 2nd ed. Dublin, Ireland: IIRRT, 2007. 4. The Michener Institute for Applied Health Sciences. Contrast injection for radiological technologist. 2013. http:// www.michener.ca/ce/course_info.php?course_group_id=4 (accessed 15 August 2017). 5. University of Malta. Administration of prescribed medicinals by radiographers. 2010. https://www.um.edu.mt/__ data/assets/pdf_file/0005/85568/IntravenousInjectionsLogbookJuly2010new.pdf (accessed 15 August 2017). 6. Koch GGV, Robbs JV. Carbon dioxide angiography for peripheral vascular intervention. S Afr Radiographer 2016;54(1):9-11. 7. American College of Radiology. ACR-SPR practice parameter for the use of intravascular contrast media. 2014. http://www.acr.org/~/media/536212D711524DA5A4532407082C89BA.pdf (accessed 31 August 2017). 8. Price RC, Edwards HM. Harnessing competence and confidence: Dimensions in education and development for advanced and consultant practice. Radiography 2008;14(suppl 1):e65-e70. https://doi.org/10.1016/j.radi.2008.11.005 9. Kelly J, Piper K, Nightingdale J. Factors influencing the development and implementation of advanced and consultant radiographer practice – a review of the literature. Radiography 2008;14(suppl 1):e71-e78. https://doi. org/10.1016/j.radi.2008.11.002 10. Munro L, Isaacs F, Friedrich-Nel H, Swindon L. An analysis of the need for accredited training on the administration of intravenous contrast media by radiographers: Results of an online survey. S Afr Radiographer 2012;50(2):27-34. 11. Gqweta N. Knowledge, skills and perceptions of diagnostic radiographers in image interpretation of chest diseases in Ethekwini public hospitals. MTech. Durban: Durban University of Technology, 2014. http://ir.dut. ac.za/handle/10321/1003 (accessed 31 August 2017). 12. Kekana RM, Swindon LD, Mathobisa J. A survey of South African radiographers’ and radiologists’ opinions on role extension for radiographers. Afr J Phys Health Educ Recreat Dance 2015;21(4):1114-1125. https://doi. org/10.20151864907 13. Koch GGV. The need for qualified diagnostic radiographers to do additional first aid and emergency procedures training. S Afr Radiographer 2014;52(2):26-28. 14. Radiological Society of South Africa. RSSA position statement on the injection of contrast. South Africa, 2011. http://rssa.co.za/downloads/doc_download/1240-rssa-position-statement-on-the-injecting-of-contrast (accessed 1 September 2017). 15. Cowling C. A global overview of the changing roles of radiographers. Radiography 2008;14(1):e28-e32. https:// doi.org/10.1016/j.radi.2008.06.001 16. College of Radiographers. Course of study for the certification of competence in administering intravenous injection. 2011. http://www.sor.org/system/files/article/201202/SoR_IV_Document_proof3.pdf (accessed 31 August 2017). 17. Royal Australian and New Zealand College of Radiologists. 2016. Iodinated contrast media guideline. https:// www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahUKEwjmyuyZ49PVAhUJDsAK HQM5CJ4QFggtMAE&url=https%3A%2F%2Fwww.ranzcr.com%2Fdocuments%2F4108-ranzcr-iodinatedcontrast-media-guideline-2016-recommendations%2Ffile&usg=AFQjCNHPWc5aRriA7OqrS0U8QVVTDdPg rw (accessed 231 August 2017). 18. Ontario Association of Medical Radiation Sciences. Intravenous injection of contrast media – competency profile. 2010. https://www.regonline.ca/custImages/300000/305453/IVInjection_CompetencyProfile.pdf (accessed 23 April 2016).

Accepted 9 November 2016.

Research

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

Perceptions of the impact of an advanced training programme on the management skills of health professionals in Gauteng, South Africa J Mutyabule,1 RN, MPH; F Senkubuge,2 MD, PhD; D Cameron,3 MD; V Pillay,4 MBA, PGCHE; P Petrucka,5 RN, PhD 1

School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda

School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Family Medicine, Faculty of Health Sciences, University of Pretoria; and Foundation for Professional Development, Pretoria, South Africa

Foundation for Professional Development, Pretoria, South Africa

College of Nursing, University of Saskatchewan, Canada; and Academics without Borders (East Africa), Canada

Corresponding author: P Petrucka (pammla.petrucka@usask.ca)

Background. South Africa’s health sector spans the private and the public sectors. Within the sectors, health managers take on strategic leadership roles without formal training in management or leadership – a trend more common in the public sector than the private sector. Health managers are selected based on their clinical skills rather than their leadership or management skills. Objective. To compare self-rated competencies in management and leadership before and after training of the participants; to assess participants’ experience of the training programme; and to evaluate the management and leadership skills of the participants after training. Methods. A cross-sectional, descriptive analytical method and 360° interviewing were used in this study. Participants were evaluated ~18 months after completion of the training programme. A 360° evaluation (360° E) of six of the 12 leadership/management competencies was done with the supervisors, colleagues, and subordinates of the participants. Results. All participants rated themselves as improved in 12 managerial and leadership competencies. The 360° E affirmed five of these competencies as improved, with the ability to create and implement a marketing plan rating poorly. Conclusion. Training in management leads to improvement in both leadership and managerial skills of health professionals. Afr J Health Professions Educ 2017;9(3):133-137. DOI:10.7196/AJHPE.2017.v9i3.696

Few medical and nursing professionals are formally trained to be leaders and managers; yet, such individuals are often called upon to assume these roles.[1-3] Traditionally, health professionals assumed managerial or leadership positions based on their clinical and scientific merits; attributes that do not necessarily equate to competency or aptitude as a leader or manager.[4] Consequently, there is frequently a perceived failure to perform or significant discontent with role fulfilment. Health providers generally expect straightforward, logical answers to every problem. These qualities may be appropriate for a clinical leader, but not so for a leader in the high-pressure business environment of healthcare, which is unpredictable, competitive and imbued with interdisciplinary conflicts, possibly making such leader incompetent. An incompetent leader often has an impact on subordinates by creating a stressful working environment and by the inability to achieve organisational objectives.[2,3,5,6] Thus, health managers/leaders experience poor job satisfaction and poor retention, impacting negatively on an organisation in terms of fiscal and human resources and organisational history.[7] Previously, health professionals moved from being a practitioner to a leader by virtue of clinical seniority – an approach that no longer reflects the realities of the health sector. ‘With the increasing complexity of health systems, the diversity of the roles and responsibilities that befall a medical manager subsequently have broadened, requiring the individual with a wider range of training and expertise than just seniority.’[8] There is growing evidence of the positive impact of formal training of health professionals in management and leadership.[9]

South Africa (SA) has prioritised healthcare management capacity building by enacting a skills development plan, as deficiencies in managerial capacity, especially in the public sector, have been identified as a risk. A survey of all managers in registered public and private hospitals in SA, found that 94.9% of public and 80.5% of private sector managers identified a need for further training in management skills development.[10] The SA National Strategic Plan prioritises the training of managers (i.e. chief executive officers, senior/district managers) to be based on a proposed assessment and gap analysis of competencies of current managers in healthcare.[11] Competency is defined as a cluster of related knowledge, skills, and attitudes that can be: (i) measured; (ii) compared with known standards; (iii) correlated with job performance; and (iv) improved by education and training.[11] A call for competency-based education in health management has emanated from professional practitioner groups, researchers, educators, and accreditation bodies.[12] The Foundation for Professional Development (FPD) offers an accredited short course – the Certificate in Advanced Health Management (CAHM). This 1-year course links course modules and assignments to participants’ work environments to optimise practical and reflective opportunities. The exit learning outcome of the CAHM is to enable participants to apply management principles at a strategic level within the healthcare environment to optimise healthcare in SA.[12] The cohort for 2009 completed their training in 2010. This study investigated the impact of the CAHM course ~18 months after training.

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Research Study design and sample size

This was a cross-sectional, descriptive analytical study of those who completed the 2009 CAHM. Data were collected using self-administered electronic questionnaires comprised of both multiple-choice and open-ended questions; the responses where deductively analysed. The questionnaire was developed by the researcher (JM) and piloted among her colleagues at FPD who had completed the CAHM. A 360° evaluation (360° E) was conducted with supervisors, colleagues and subordinates as assessors. It is now popular for assessing employee performance in the private and public sectors, as it involves seeking opinions from a spectrum of stakeholders well positioned to reflect on the employee’s job performance and effectiveness. The 360° E gathers perceptions, from those directly affected, about an employee’s behaviour and the impact of his/her behaviour on job effectiveness. The advantages of the 360° E include minimising performance-appraisal errors, and providing a broad-scoped assessment and improved assessment reliability. The questionnaire was sent electronically to all CAHM-qualified doctors and nurses (n=17) and participants’ assessors (n=51). Although the CAHM participant intake was 44, only 17 were health professionals. Sixty-eight participants were surveyed, with 40 responses (59% response rate), of whom 10 (25%) were CAHM trainees and 30 (75%) assessors.

Data collection and measurement

The questionnaire assessed 12 self-rated competencies across 11 domains of leadership and management (Table 1). The 11 domains reflect emotional intelligence, and interpersonal, technical and conceptual/analytical abilities of the participants. Data collection included demographic information, number of staff supervised, annual operating budget for which they are responsible, and if the participants received management training before CAHM. Data relevant to the CAHM course were also collected, such as the participants’ personal highlights, relevance to their work, recommendation to other managers in the health sector, influence on achieving organisational strategic objectives, impact of training on their work, and any changes with regard to salary, job promotion, and/or increase in responsibilities.

Competency self-assessment by CAHM graduates In pre- and post-training self-ratings of the 12 competencies (Fig. 1A and B), CAHM participants indicated considerable improvement in leadership and managerial skills after training. Areas of significant growth between pre-periods (T1) and post-periods (T2) were writing and evaluating strategic plans (T1 – 0%; T2 – 90%), assessing organisational design choices (T1 – 0%; T2 – 90%), and obtaining funding for the organisation (T1 – 0%; T2 – 90%). Competencies, such as creating and implementing monitoring and evaluation plans, or creating budgets and performing budget variance analysis, were rated by participants as areas of significant growth. All competencies showed improvement after the course in self-rating (Fig. 1A and B). The smallest shift from pre- to post-training occurred in managing time effectively and leading individuals and teams. Stakeholder 360° evaluations The 360° E by the supervisors, colleagues, and subordinates assessed 6 of 12 core competencies (Fig. 2). Agreement by two or more assessors on a particular skill is interpreted as competence in that skill; conversely, if only one assessor rates a participant as competent then the health manager is assumed to be incompetent in that skill. The 360° E affirmed that 80% of CAHM graduates were seen as competent to write and evaluate strategic plans; manage time effectively; lead individuals and teams; and develop and implement monitoring and evaluation plans after training. Additionally, 120

100

100 90

80 70

70 Participants, %

Methods

Results

Quantitative results

Sample demographics A range of demographic/supervisory characteristics are reflected in Table 2. Of note, public-private participation was equal. Most participants were female (80%) and nurses (60%), half were in managerial positions for <2 years, and 70% reported no prior management training. Reflecting on managerial roles (Table 3), the training was highly influen tial in areas of relevance to job roles (100%), actions impacting on strategic achievements (80%), and job augmentation (60%).

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Not sure Needs help

Can do 50 40

50 50

40 30 30

20 10

Write and evaluate strategic plans

Assess organisational design choices

20 10

Create Gantt charts

10 10

Create a marketing plan

Perform financial statement analysis

Create budgets and perform budget variance analysis

Management skills

Data analysis

120

100

100 90

90 80

80 70

Participants, %

Data were entered into Epi Info (Centers for Disease Control and Prevention, USA) and then exported to Stata 11 (StataCorp., USA) for analysis. Frequencies calculated for categorical variables reflected association of the training course with change in management practices. Fisher’s χ2 tests to compare pre- and post-training competencies addressed the small sample size. Statistical significance was set as p<0.05. Open-ended questions were transcribed and thematically analysed.

70 Not s ure

Needs help Can do

40 40

20 10

Obtain funding for the organisation

20 10

Perform qualityimprovement analysis

Analyse the organisation's operations strategy

Develop M and E indicators

Management skills

Lead individuals and teams

Manage time effectively

Fig. 1. (A and B) Self-rated competencies in select management and leadership skills before and after training. (T = time; CAHM = Certificate in Advanced Health Management; M = monitoring; E = evaluation.)

Research Table 1. Domains for self-assessment

Domains Leadership

Understanding of a healthcare environment Strategic and operational management

Table 3. Participants’ perspectives on CAHM outcomes (N=10) Perspectives Managing yourself Project management

Yes

10 (100)

0 (0)

Relevance to work

Managing information

Resource mobilisation and donor relations

Financial management

Human resource management

Strategic marketing and customer relations

Action research

Characteristic

n (%)

Organisation type Private Public Gender

5 (50) 5 (50)

3 (30)

Very relevant

7 (70)

Achievement of strategic targets

2 (20)

Female

8 (80)

Diploma

1 (10)

Bachelor’s degree

5 (50)

Master’s degree

4 (40)

Profession

Nursing

6 (60)

Medicine

4 (40)

Prior management training

Yes

3 (30)

7 (70)

Management role (years)

Yes

8 (80)

2 (20)

Better job offer/promotion

1 (10)

Promotion and increase in responsibilities

1 (10)

Increase in responsibilities

4 (40)

No change in job profile

4 (40)

CAHM = Certificate in Advanced Health Management.

Male Highest qualification

Relevant

Impact on current position

Table 2. Demographic information for CAHM participants (N=10)

n (%)

Recommend

1 (10)

1-2

4 (40)

>2 - 5

1 (10)

4 (40)

Budget oversight (ZAR) >1 000 000

5 (50)

500 000 - 1 000 000

1 (10)

100 000 - 500 000

4 (40)

CAHM = Certificate in Advanced Health Management.

70% of respondents felt that the participants were competent in financial management. A negative difference occurred between the 360o E and selfrated levels of creating and implementing a marketing plan competency. Statistical significance It is possible that the small number of participants in the study affected the lack of statistical significance in comparing competencies at T1 and T2 (Table 4).

Table 4. Fisher’s χ2 comparative test for management competen cies (pre- and post-training) Competency

p-value

Write and evaluate strategic plans

1.00

Assess organisational design choices

0.40

Create Gantt charts

0.40

Create a marketing plan

1.00

Perform financial statement analysis

0.40

Create budgets and perform budget variance analysis

0.60

Obtain funding for the organisation

1.00

Perform quality improvement analysis

1.00

Analyse organisation’s operative strategy

0.80

Develop monitoring and evaluation indicators for projects

1.00

Lead teams and individuals

0.40

Manage your time effectively

0.11

Qualitative results

Both CAHM participants and stakeholders provided feedback on their perceptions and experiences with the course. For the graduates, these comments aligned mainly with the impact on their work and use of action research as a tool. Stakeholder comments aligned with the impact of training on participants and potential recommendations of CAHM for future health managers. Impact on CAHM participants’ work Reflection by CAHM participants on how the course affected their work was captured under three themes: successful programme implementation; job promotion; and work relationships. Five participants indicated that the skills learned through CAHM had practical implications for their ability to act and successfully implement a programme. The course enabled application of management skills in their work environments and projects such as skills-enabling proposal writing, improving approvals, and project implementation. One participant stated:

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Research ‘ Through action research we have come up with better ways to control stock. A stock audit was performed at all sites and more than ZAR500 000 was saved through this exercise.’

120 100

CAHM participants, %

100

90 80

40 20 0

Incompetent Competent

30 20 10

10 0

Ability to Ability to lead Ability to Possession Ability to write Ability to individuals manage time develop M of financial create and and use effectively and teams and E implement a management strategic indicators skills marketing plans and an M and plan E plan

Management skills

Fig. 2. Assessment (360°) on select competencies in leadership and management (post training). (CAHM = Certificate in Advanced Health Management; M = moni toring; E = evaluation.)

‘ I was able to submit my mentorship project to my organisation’s top management in a more structured and comprehensive way and it was approved. The mentorship is actually happening … .’ Within the theme of job promotion, skills learned were very relevant and practical for health managers, making them more dynamic and effective change agents. Therefore, a competently skilled health manager is beneficial, as described by one graduate: ‘I used the analytical methods of the CAHM to do strategic planning for the organisation and this resulted in a change for the organisation. And therefore I was given a new position.’ Four respondents’ contributions informed the third theme, ‘Better workplace relationships’, highlighting participants’ capacities to manage diverse people and situations. One participant observed: ‘Dealing with and managing people is not an easy task … I now possess people skills … .’ Through CAHM, participants first understand themselves and how their presence has an impact, both negative and positive, on colleagues and subordinates, thereafter increasing awareness of relationships. Use of action research and problem-solving Action research is a practical tool that a manager can apply to identify and also solve a problem and prevent it from re-occurring. Not only does this approach improve the use and creation of evidence, but it also promotes dissemination of evidence within the workplace and beyond. Three themes were derived from the participant contributions related to the uptake and utilisation of action research: self-improvement; programme improvement; and work environment improvement. Within the first theme (self-improvement), participants referred to the potential of using action research as part of one’s career development, including dissemination of ‘action research results to both national and international conferences’. With regard to the second theme (programme improvement), participants indicated that this ‘tool’ was invaluable to their organisations’ development. One participant stated:

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As for the final theme (improving the workplace environment), action research can have an immediate effect and increase personnel involvement, as indicated in the following comment: ‘Action research was used to improve the absenteeism rates in my workplace.’

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Impact of training on CAHM participants Through 360o E, one recurring theme regarding the effect of the CAHM programme on participants was ‘improved management and leadership skills’. The course increased participants’ scope of management skills and extension of responsibilities, catalysing their visibility as leaders in their organisations and healthcare networks. Supervisors indicated that these individuals were now able to influence programmes within and beyond their own workplace by ‘effectively leading a team of peer educators … [and] successfully networking with partners’. Colleagues indicated that CAHM graduates have garnered increased respect owing to improved quality of work (e.g. being very professional and very thorough) and increased levels of confidence in their work. This was evidenced as follows: ‘The CAHM sharpened and enhanced the participant’s managerial skills in general … added more substance to the content of his knowledge on the principles of leadership and management.’ Subordinates indicated that CAHM graduates improved the work environment, impacting on the quality and levels of team participation. Subordinates also found evidence of application of technical skills after the CAHM course in areas such as development of practical organisational strategic plans. A respondent described this as follows: ‘The strategic plan she has developed and uses was much needed by the company and the community. She has involved the entire team in the project and everyone is given a chance to contribute their thoughts.’ Assessors’ perspectives on recommending CAHM In stakeholder recommendations on CAHM for future candidates, two key themes emerged: positive impact due to training; and need for training in management. Supervisors and colleagues recommended CAHM, as it contributed to significant growth in skills and capacities of the graduates. One of the supervisors stated: ‘The impact and change the course has brought to those exposed to it is of great value.’ Regarding the second theme (need for training for managers), both colleagues and subordinates commented on the positive impact of the training on the wider workforce. According to one respondent: ‘The CAHM unfolds your potential. All managers need it.’

Discussion

The key result from participants’ self-rated competencies and the 360o E is that participation in CAHM led to improvement in graduates’ leadership and managerial skills. Self-rated competencies indicate that, after training, ≥70% of participants were competent in each of the 12 management skills. Similarly, the 360o E confirmed competency in five of the six explored management skills, with an evaluated competency level of ≥70%.

Research Self-rated competency on finances was low, possibly attributed to gender differences in self-ratings. Female self-rated competencies were lower than those of males in several areas. Furthermore, organisations do not focus sufficiently on health managers having skills to manage business complexities of client care, such as budget management.[9] The 360o E compared perceptions of stakeholders to provide the assessed individual with a clearer picture of strengths and weaknesses, and to clarify expectations. It increases reliability of individual self-ratings. The 360o E monitors progress, with identification of training priorities and coaching interventions.[13] In this assessment, participants scored poorly in the creation of a marketing plan and its implementation.

Study limitations

In terms of study limitations, 44 individuals participated in the CAHM; however, only 17 were health professionals and met our inclusion/exclusion criteria. The small number of participants had an impact on statistical significance and limited generalisability of results. Furthermore, this study involved primary collection of data through self-administered questionnaires; therefore, the data were subject to recall information bias.

Conclusion and recommendations

Graduates and key stakeholders perceived training in an advanced management course, such as CAHM, as beneficial to health professionals in Gauteng. Our data indicate improvement in areas of leadership, financial management, monitoring and evaluation, strategic planning, and time management. Competency to develop a marketing plan was positively self-rated by health managers, but was not viewed as a realised competency by the 360o E. All trained health managers indicated that the course was relevant or very relevant to their work and highly recommended it for other health managers. This was mirrored by stakeholder comments, which also recognised the positive impact of the CAHM on health managers and recommended it to other managers in the health sector. Further research is needed with a larger sample to address statistical significance and generalisability. This study only considered six of 12 management skills in the 360o E and should be expanded to all 12 in a future

study iteration. The 360° assessment tool was considered a strength in this study; hence, future use and implications of this approach should be further explored. Finally, the potential to compare impacts and implications with management/leadership across sectors is possible given the mix of participants in the CAHM programme. Acknowledgements. We thank the following contributors to the study: Profs S Manda, A McIntyre, T Mampe and B English. We also thank the Foundation for Professional Development (FPD) for their permission to conduct the study at their institution. Author contributions. JM: involved in all aspects of this project from inception through publication; FS, DC, VP: supervised tool development and the research process; and PP: involved in the analysis and dissemination phase. All authors contributed to the final publication and editing. Funding. None. Conflicts of interest. The researcher (JM) was employed by the FPD at the time of the study. The FDP supports this journal. 1. Strack van Schijndel RJ, Burchardi H. Bench-to-bedside review: Leadership and conflict management in the intensive care unit. Crit Care 2007;11(6):234. https://doi.org/10.1186/cc6108 2. Green TP. Management skills of intensivists influence outcomes in pediatric intensive care units. Pediatr Crit Care Med 2007;8(6):587. https://doi.org/10.1097/01.PCC.0000288707.41243.F1 3. Harrison T, Gray AJ. Leadership, complexity and the mental health professional. A report on some approaches to leadership training. J Ment Health 2003;12(2):153-159. https://doi.org/10.1080/0963823031000103461 4. Ersson A, Chew M. Evidence-based approach to intensive care unit management: Need for improvement. Crit Care 2008;12(1):404. https://doi.org/10.1186/cc6763 5. Nielsen K, Yarker J, Brenner SO, Randall R, Borg V. The importance of transformational leadership style for the well-being of employees working with older people. J Adv Nurs 2008;63(5):465-475. https://doi.org/10.1111/ j.1365-2648.2008.04701.x 6. McLarty J, McCartney D. The nurse manager: The neglected middle. Healthcare Finan Manage 2009;63(8):74-78. 7. Reed S. Ward management: Education for senior staff nurses. Paediatr Nurs 2008;20(3):27-31. https://doi.org/10.7748/ paed2008.04.20.3.27.c6518 8. Dwyer AJ. Medical managers in contemporary healthcare organisations: A consideration of the literature. Aust Health Rev 2010;34(4):514-522. https://doi.org/10.1071/AH09736 9. Dierckx de Casterle B, Willemse A, Verschueren M, Milisen K. Impact of clinical leadership development on the clinical leader, nursing team and care-giving process: A case study. J Nurs Manage 2008;16(6):753-763. https:// doi.org/10.1111/j.1365-2834.2008.00930.x 10. Pillay R. Managerial competencies of hospital managers in South Africa: A survey of managers in the public and private sectors. Hum Res Health 2008;6(4). https://doi.org/10.1186/1478-4491-6-4 11. National Department of Health. Strategic Plan 2010/11 - 2012/13. Pretoria: NDoH, 2014. 12. Foundation for Professional Development. Certificate in Advanced Health Management. Study guide. Pretoria: FPD, 2009. 13. Kim PS. Utilising 360-degree feedback in the public sector: A case study of the Korean central government. Asian J Pol Sci 2001;9(2):95-105. https://doi.org/10.1080/02185370108434193

Accepted 11 July 2016.

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Research

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

A peer evaluation of the community-based education programme for medical students at the University of Zimbabwe College of Health Sciences: A southern African Medical Education Partnership Initiative (MEPI) collaboration D Michaels,1 BSocSc, MPhil (Maternal and Child Health), MSc (Epidemiology), PhD; I Couper,2 MB BCh, MFamMed; M S Mogodi,3 MB ChB, MPH; J G Hakim,4 MB ChB, MMed (Internal Medicine), MMedSci (Clinical Epidemiology); Z Talib,5 MD (Internal Medicine); M H Mipando,6 BEd, MSc; M M Chidzonga,4 BDS, FFDRCSI, MMedSci (Clinical Epidemiology), PGD IntResEthics; A Matsika,4 BBS, MBA; M Simuyemba,7 BSc, MB ChB, MPH 1

School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa

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

Faculty of Medicine, University of Botswana, Gaborone, Botswana

University of Zimbabwe College of Health Sciences, Harare, Zimbabwe

Medical Education Partnership Initiative (MEPI) Co-ordinating Centre, George Washington University, Washington DC, USA

College of Medicine, University of Malawi, Blantyre, Malawi

Medical Education Partnership Initiative (MEPI), University of Zambia, Lusaka, Zambia

Corresponding author: D Michaels (desireclas@gmail.com)

Background. The University of Zimbabwe College of Health Sciences (UZCHS), Harare, which has a long tradition of community-based education (CBE), has not been evaluated since 1991. An innovative approach was used to evaluate the programme during 2015. Objectives. To evaluate the CBE programme, using a peer-review model of evaluation and simultaneously introducing and orientating participating colleagues from other medical schools in southern Africa to this review process. Methods. An international team of medical educators, convened through the Medical Education Partnership Initiative, worked collaboratively to modify an existing peer-review assessment method. Data collection took the form of pre-visit surveys, on-site and field-visit interviews with key informants, a review of supporting documentation and a post-review visit. Results. All 5 years of the medical education curriculum at UZCHS included some form of CBE that ranged from community exposure in the 1st year to district hospital-based clinical rotations during the clinical years. Several strengths, including the diversity of community-based activities and the availability of a large teaching platform, were identified. However, despite the expression of satisfaction with the programme, the majority of students indicated that they do not plan to work in rural areas in Zimbabwe. Several key recommendations were offered, central to which was strengthening the academic co-ordination of the programme and curriculum renewal in the context of the overall MB ChB curriculum. Conclusion. This evaluation demonstrated the value of peer review to bring a multidimensional, objective assessment to a CBE programme. Afr J Health Professions Educ 2017;9(3):138-143. DOI:10.7196/AJHPE.2017.v9i3.733

The Medical Education Partnership Initiative (MEPI) was a large-scale, US government investment in strengthening the health workforce in Africa by providing medical schools with funding to implement activities based on local needs and priorities. Schools that were awarded the grant chose to invest in strengthening community-based education (CBE) and formed a technical working group convened by the Coordinating Centre of MEPI (a partnership of institutions also funded by the MEPI grant). The technical working group collaborated with CapacityPlus (a US Agency for International Development (USAID)-supported programme with funding specifically allocated to work with the MEPI schools) to strengthen their CBE programmes.[1] Within this context, the University of Zimbabwe College of Health Sciences (UZCHS) requested a peer review of its CBE programme. The evaluation served as a learning exercise for both UZCHS and other medical schools in the MEPI network in applying the peer-review process while evaluating the UZCHS CBE programme.

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CBE is increasingly included as part of health sciences curricula across the globe. It forms part of an educational strategy to address the worldwide inequities in human resources for health by preparing graduates for service to rural and under-served populations.[2] The protocol developed by the Collaboration for Health Equity through Education and Research (CHEER) was adapted for use by UZCHS to evaluate its CBE programme. CHEER was formed in South Africa (SA) during 2003 to examine strategies that would increase the likelihood of health professional graduates choosing to practise in rural and under-served areas.[3,4] Since then, the CHEER model has demonstrated effectiveness in examining complex outcomes in medical education in countries other than SA, as reported by S Reid on the University of Cape Townâ&#x20AC;&#x2122;s Primary Health Care Directorate website (www. primaryhealthcare.uct.ac.za/). The medical school in Harare, Zimbabwe was established in 1963 and runs a 5-year undergraduate medical programme (MB ChB). The uni-

Research versity’s intention to expose students to CBE originated with the idea of a ‘village family scheme’, whereby students were attached to families in rural areas.[5] The evaluated format of the CBE programme was formally launched in 1987. At the time of the peer review, 22 academic departments and 67 clinical teaching sites contributed to the implementation of the programme.

Institutional agreement on need for evaluation of CBE

Objective

The aim of the review was to train colleagues from the network of MEPI schools in using the CHEER approach (Fig. 1) and to conduct an evaluation of how the medical school’s CBE programme served to encourage future rural practice. The specific objectives were: (i) to identify gaps between theory and practice in education and training; (ii) to provide a report for ongoing curricular review; and (iii) to share best practices regarding preparation of students for practice in rural and under-served areas.

Methods

A descriptive study design, using mainly qualitative methods that focused primarily on semi-structured interviews and review of supporting documentation, was employed. In addition, a pre-visit questionnaire was distributed to faculty and students for completion from September to December 2014 to serve as baseline data prior to the review visit. All respondents for pre-visit questionnaires were identified by representatives of UZCHS using convenience sampling, whereby as many students and appropriate staff as were available were invited to complete the forms. Purposive sampling was done for the on-site face-to-face interviews in February 2015 through the identification of appropriate key faculty members and students, as well as graduates and clinical preceptors at two district hospitals. During the visit, an initial presentation of the findings and recommendations was made to the faculty to corroborate and supplement the findings. A follow-up visit to present final key findings and recommendations was conducted during May 2015; this meeting was also used to further validate the findings prior to drafting a final written report. Two facilitators from SA (IC and DM), who were experienced in the CHEER peer-review approach, led a team of representatives from the medical schools in Botswana, Zambia and Malawi, who served as peer reviewers while being orientated to the evaluation process. Representatives of UZCHS were involved in the process, which commenced ~7 months prior to the visit and involved protocol adaptation and questionnaire distribution. During the visit in February 2015, the reviewers divided into two subteams and conducted interviews of ~1 hour. Written notes were taken during the interviews, which were conducted with individual faculty members or pairs from the same department. Written, informed consent was obtained from each interviewee prior to commencement of the interview. Students presented in two large groups of ~50 students each. Each group was seen separately but in parallel. Due to the large numbers of students, a paper response method was used to encourage response, whereby each student was handed a slip of paper on which to write their answer. Following each response, the paper was handed in and a brief discussion ensued to identify common issues.

Analysis

Analysis of pre-visit staff questionnaires was done using a grid to summarise answers to the questions as a result of a paucity of responses. The responses to the pre-visit student questionnaires were captured at UZCHS using the REDCap (USA) database. The descriptive analysis was conducted by members of the peer-review team in SA, with online access to the database. Thematic analysis was conducted on the qualitative aspects of the survey.

Pre-visit preparation

Pre-visit desktop review and surveys

Post-review consultative workshop and final report Peer-review visit Analysis, preliminary report

Obtain stakeholder buy-in for review Invite peer reviewers Protocol development and approval Invite participants

Pre-visit student and faculty surveys and analysis Review institutional documentation Prepare interview guides

Workshop One-hour interviews with individuals/pairs of faculty members, deans and HODs

Final report

One-hour focus group discussions with students Field visits with clinical preceptors Presenting of preliminary results

Remote mentorship

Fig. 1. The Collaboration for Health Equity through Education and Research (CHEER) peer-review process at the University of Zimbabwe College of Health Sciences. (CBE = community-based education; HODs = heads of department.)

All data from on-site interviews were analysed using recursive abstraction and summarised along broad themes outlined in the interview schedule based on the CHEER evaluation framework (Table 1), including the nature of involvement of each department in CBE (Table 2). The results were discussed by the review team, with consensus being reached on themes within and across the interviews. The students’ paper responses to the structured questions were analysed using a thematic approach. Research ethical approval was granted by the Medical Research Council of Zimbabwe (MRCZ) on 9 June 2014 (ref. no. MRCZ/A/1841).

Results

The CBE programme at UZCHS was found to be constrained by a number of remote and recent pressures, including the financial crisis in Zimbabwe, increasing staff shortages, increased student numbers, and deteriorating infrastructure. Despite these pressures, which had evolved over time, the programme had expanded from 10 purpose-built sites in eight provinces to more than 60 sites across all provinces, with positive relationships between the university, the Ministry of Health and Child Care, mission hospitals and private medical care providers in the mining industry.

Pre-visit survey results

The pre-visit surveys conducted from November to December 2014 resulted in a low response rate, with 5% (n=54/1 164) and 26% (n= 5/19) of students and faculty responding, respectively. Key findings from the student survey were as follows: the majority (94%) did not plan to practise in rural or underserved areas upon graduation; community health workers were perceived as the most significant ‘teachers’ not employed by the university; and half of the respondents were in contact with graduates. The low response from faculty resulted in inadequate baseline data being available to reviewers. Faculty respondents were mainly involved with the clinical years (years 3 - 5), and none reported being involved in the CBE programme. All indicated that there was no policy that specified student recruitment from rural or underserved areas.

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Research Table 1. Adapted CHEER evaluation framework Score Criterion number 1

Evaluation criteria

Less than expected

Adequate

Better than expected

Faculty mission statement

R/U not mentioned*

Some mention or indirect reference

Explicitly supportive

Stated: ‘Community-orientated and community-driven training and learning’† Issue of social accountability – where graduates go not addressed† 2

Resource allocation

None†

Some staff and funding, but not enough*

Sufficient staff and funding for sustainability

Biggest constraint. Worked well with external funding. The financial crisis had a major negative effect† 3

Student selection

No policy with regard to R/U*

Some policy with regard to R/U

>25% rural origin

None Reported that most students come from lower SES backgrounds† †

First exposure

Final year, if at all

Middle years

1st year*

Behavioural sciences convene 1st-year exposure† Exposure in every subsequent year† 5

Length of exposure

None†

<5%*

>25% of practical in R/U areas

4 - 8 weeks/year (1 - 5 days/week for the duration of attachment)† 6

Practical experience

None†

Students watch and listen to others

Students hands-on and contributing*

Develops over the years; 5th year very hands-on† 7

Theoretical input

None†

R/U mentioned*

Critical reflection on R/U issues

Mainly in community medicine; some reference in other disciplines

†

Involvement with community

Tourism-type exposure*

Engagement or intervention

Ongoing joint reflection

Learn from the community, but don’t contribute to it; unlike the rehabilitation sciences students† 9

Relationship with health service

Students are a drain/burden

Students are tolerated

Students’ input is welcomed and used*

Very positive (especially senior years)† 10

Assessment of students

No formal assessment for rural learning

Assessment was done, but not pass/fail*

Pass/fail contribution from rural component

Reports and presentations compulsory, but no rigorous assessment of knowledge and skills acquired during CBE† 11

Research and programme evaluation

No programme evaluation or reflection*

Evaluation is done, but not specific to R/U

Current educational research with regard to R/U

Some academic oversight at departmental level; some academic co-ordination

Good co-ordination with seniorlevel support and academic oversight

None† 12

Programme oversight and co-ordination

No academic co-ordination; administrative co-ordination only*

There was good administrative co-ordination from the dean’s office† CHEER = Collaboration for Health Equity through Education and Research; R/U = rural/under-served; SES = socioeconomic status. *Reviewers’ score. † Reviewers’ explanatory comments for choosing the score.

Review visit results

Face-to-face interviews were conducted with the dean, 23 faculty members in preclinical and clinical departments, four recent graduates and two off-site clinical preceptors. Modified group interviews were conducted with 3rd-year (n=69) and 4th-year (n=52) students. Several strengths and challenges were identified using the CHEER evaluation framework, as illustrated in Table 1. The faculty mission statement does not overtly mention rural and under-served populations, but states that the institution strives for ‘community oriented and community driven training and learning’. The

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length of exposure to field attachments was estimated to be ~5% per year on average, with time spent ranging between 1 and 5 days per week for 4 - 8 weeks within one study year (Table 2). The community medicine curriculum provides theoretical input regarding healthcare in rural or under-served areas. Staff who supervise the preclinical and clinical field attachments are mostly non-clinicians and often work under difficult circumstances; yet, the programme boasts a large teaching platform (in excess of 67 sites across all provinces and districts in Zimbabwe), providing various exposure options.

Research Table 2. Summary of student exposure to community-based education Year

Site

Duration

Department

Focus

Epworth (peri-urban)

Fridays: 2 × 8 weeks

Behavioural sciences (psychiatry)

Health-seeking behaviour; family health study

Communities around district sites: variable numbers

4-week block

Community medicine focus; all departments involved

Community characteristics, needs and structure

District hospitals in various towns

4-week block

‘Field attachment office’ (deanery); all departments involved

The health system; clinical skills (ward rounds, patient clerking)

Urban clinics

4-week practicum

Community medicine

Maternal and child health focus; general primary care medicine

District hospitals in various towns

4-week block

‘Field attachment office’ (deanery); all clinical departments involved

Core clinical disciplines; audit (ward rounds, patient clerking and ongoing patient management)

Table 3. Key recommendations Key recommendations (presented)

Table 4. Post-review visit: Key outcomes Key recommendations (adopted)

Identify academic co-ordinator for CBE

Identify academic management structure for CBE Monitoring and evaluation

Revise CBE programme based on review results

Revise field attachment programme* to evolve into CBE based on results of review

Integrate CBE programme across medical departments

Integrate the MB ChB CBE programme across all teaching departments

Align learning objectives with the overall medical curriculum

Align CBE learning objectives with the overall medical curriculum

Launch a parallel medical curriculum revision process Align teaching platform to learning outcomes Increase CBE exposure time across the years

Align teaching platform to learning outcomes Increase CBE exposure time across the years

Improve student supervision

Attend to student accommodation, transport, maintenance and resources issues

CBE = community-based education. *University of Zimbabwe College of Health Sciences referred to existing CBE activities as the field attachment programme. Note: The column on the left indicates recommendations made by the peer-review team, while the column on the right indicates the consensus reached by the university representatives, including the dean.

Strengths

There are a number of areas where UZCHS performed better than expected using the peer-review tool: early exposure to rural and under-served communities occurs from the 1st year onwards; CBE occurs in every year of study; practical experience is afforded to students during community-based activities (although the extent depends on their year of study, with more senior students having more ‘hands-on’ clinical experience); and a good relationship with health service personnel and the ministry of health. The establishment of a Health Professions Education Department in 2014 was intended to encourage and facilitate the training of clinicians and other academics in educational approaches and skills.

• The establishment of a working committee for CBE revision. The first meeting of the committee was planned for 2 weeks from the date of the post-review meeting. The dean called the meeting and confirmed the convenor of the committee. • The appointment of a convenor of this working group, who was nominated by the dean (the head of the HPE Unit). • The inclusion of CBE in the staff development programme originally planned to focus on MB ChB curriculum planning. • The agreement that the CBE curriculum review would take place in the context of the overall MB ChB curriculum revision. • The agreement that student supervision will be revised and improved to include an academic component. The HPE Unit will develop an orientation programme for all supervisors to support the strengthening of CBE. This orientation will include a revision of the guidelines for supervision as per the new goals set for competencies that students should achieve during the field attachment. • The agreement that HEALZ graduates from UZCHS would be co-opted to assist the HPE Unit and the CBE curriculum committee with the curriculum revision of the CBE programme. • It was agreed that UZCHS will explore the implementation of innovative funding strategies for the CBE programme. CBE = community-based education; HPE = health professions education; UZCH = University of Zimbabwe College of Health Sciences; HEALZ = Health Education and Advanced Leadership for Zimbabwe.

Accommodation at two field sites was upgraded in 2014/2015 and internet facilities were expanded, including a repository for textbooks and assignments. Students value and enjoy the CBE experience, despite the poor living conditions at some sites due to lack of adequate maintenance, oversight and funding. They reported that the experiences impacted positively on their personal growth, empathic skills and professionalism.

Challenges

A number of limitations and challenges emerged. The institutional oversight and investment was limited, evidenced by the last MB ChB curriculum having been reviewed in the 1980s and the last substantial amendments to the field attachment programme made in the 1990s. The relationship between the medical school and the community leans towards a ‘tourismtype’ exposure, with no evidence of a partnership with the community, especially during the non-clinical years. The dean has provided high-level support and visibility for the programme and administrative oversight for the 2nd-, 3rd- and 5th-year

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Research CBE programmes, but the transfer of the programme to his office appears to have created a gap in the day-to-day academic oversight and co-ordination of the programme. Faculty and students report ‘silo’ learning or a lack of integration between disciplines, and perceive a disconnect between the objectives of the CBE programme and the overall MB ChB curriculum. Supervisors and clinical preceptors reported a poor understanding of the specific objectives of the CBE programme, particularly in the clinical years, as well as dissatisfaction with some of the infrastructure, support materials and resources available to implement the programme. Students reported inadequate supervision from medical professionals during communitybased activities. The various teaching departments reported that they do not have any overt teaching and learning outcomes for the CBE placement, and while there is some assessment of students’ CBE experience in the form of reports and presentations and during the behavioural sciences course examinations in the 1st year, it is not rigorously assessed throughout the study years. Clinical skills proficiency was identified by preceptors as a major gap in students’ capacity during field placements. Senior students reported that they were not adequately prepared to practise in rural areas, which lacked adequate nearby referral networks and required them to perform clinical skills they were not comfortable with. Despite their generally positive CBE experiences, most students reported that they have no intention of practising in rural or under-served areas when they qualify.

Key recommendations for UZCHS

The recommendations presented by the review team were generally well received and feasible, with some modifications (Table 3). The central recommendation was that UZCHS needed to strengthen the structures for curriculum review and academic co-ordination of the CBE programme and assign a person or group to the academic co-ordination of the programme. Other key recommendations included: (i) to convert the current ‘field attachment’ into a formal CBE programme, ensuring that there is a spiral of learning that links CBE activities from one year to the next with increasing levels of competency; (ii) to align learning objectives of the CBE programme with the overall medical curriculum, leveraging international guidelines, such as the Global Consensus on the Social Accountability of Medical Schools,[6] the Lancet Commission Report,[7] the World Health Organization’s Transformation of Health Professions Education, 2013,[8] and the approach of evidence-based medical education;[9,10] (iii) to improve student supervision and set clear learning objectives and outcomes, thereby integrating knowledge across disciplines and ensuring skills proficiency; and (iv) to consider the introduction of family medicine to strengthen the provision of primary care, while postgraduate trainees in family medicine could potentially provide supervisory support to undergraduate students during CBE placements. Other recommendations included reviewing the existing teaching sites to ensure they each provide appropriate learning opportunities, strengthening inter-professional learning through the CBE experience and improving the infrastructure (of accommodation and the health facilities), recognising that the latter will require political will and innovative income-generating strategies.

Post-review visit results

A 2-day meeting reviewing the recommendations with the dean, heads of department, and key faculty led to several main decisions and plans for improvement of the CBE programme (Table 4). One of the key decisions, taken in the absence of available funding for an academic co-ordinator, was to convene a working committee chaired by the head of the Health Professions Education Department to provide academic oversight of the

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CBE programme. Remote support was provided to the institution by the review team to facilitate implementation of adopted recommendations.

Discussion

Peer review is not an accreditation process but rather focuses on providing health sciences schools with organising principles and an opportunity to reflect on the institutional standards and curriculum, which will help them become more accountable in addressing some of the health inequities and improvements to the health system. The process of the review supported peer reviewers to learn from each other and share their experiences, similar to the in-country consortia of medical schools that formed within the MEPI network.[11] Medical schools in the region share common constraints of limited resources and infrastructure[12,13] and many face the challenge of finding funding for objective programme evaluations. The peer-review approach therefore affords a cost-effective mechanism to provide valuable feedback. The post-visit support was a modification of the CHEER model and may well be a feature that others can incorporate in the future.

Common challenges shared with other MEPI schools

UZCHS has several challenges in common with other MEPI partners regarding the CBE programme, such as inadequate clinical preceptorship at CBE sites, increasing admission numbers and limitations of infrastructure and logistics, which include inadequate internet connectivity for online technology expansion, accommodation and transport.[1] Other key areas needing attention relate to the CBE curriculum, appropriate course materials, textbook availability and alignment with the central curriculum. These challenges may undermine a major aim of CBE, which seeks to expose students to rural and under-served communities with the objective of encouraging future practice in these areas. Despite the positive sentiments expressed about the CBE experience, most students at UZCHS would not choose to practise in rural areas in future. This does not bode well for Zimbabwe, considering that the majority of the population (67%) live in rural areas and are dependent on government health services.[14] This finding contradicts previous findings that the exposure to CBE in medical curricula increases the likelihood of graduates choosing to work in rural and under-served areas.[1,15] Perhaps it is not just exposure to CBE (which in practice spans each year at UZCHS), but the quality and nature of that exposure which impacts positively on graduate choice. Studies have shown that three main factors influence choice of rural practice by medical graduates, i.e.: (i) rural origin; (ii) positive clinical and educational experience in rural placements during undergraduate medical training; and (iii) targeted postgraduate training for rural practice.[16,17] There is no explicit student recruitment and selection policy aimed at students from rural origin at UZCHS, with the majority reporting being of urban origin, and no postgraduate rural training is offered. Therefore, all three factors may be linked to graduate choices at UZCHS.

Key lessons

While the on-site review occurs within a relatively short space of time (3 - 5 days), the entire process takes several months.[18] Hosts and reviewers must therefore be committed to participation throughout the entire process. Buy-in from key stakeholders is important to gather meaningful information and to implement recommendations. The purpose of evaluation is to identify whether a programme meets its objectives. Without clearly articulated programme goals, evaluation is challenging.

Research A specific area of focus for the review is important, as there is a danger of covering too much (depth v. breadth). External peers can offer safe, empowering and multifaceted support to improve and evolve educational programmes within institutions, while enjoying a mutual learning experience. Peer review is a fluid process and the approach is one of a conversation with supportive peers, with openness to adaptation. The protocol should, therefore, not be rigidly adhered to if it is not effective in a particular context. In this instance, the addition of the 12th criterion to the evaluation framework was deemed an important adaptation for the UZCHS context, and probably also for other CBE programmes.

Study limitations

Data collection of pre-review-supporting documentation and completion of course curriculum spreadsheets was unsuccessful owing to the very poor response from faculty. This led to interviews being focused mainly on gathering general information without adequate time for in-depth probing. Daily debriefing sessions of the reviewer team with the host institution’s academic representatives would have been very helpful in clarifying issues as they arose. Incorporating such meetings into the daily schedule would be best. Only two community-based sites were selected because of their proximity to the university. Thus, the reviewers relied on the two preceptors to relate their experiences and perceptions rather than gaining first-hand information and observations beyond the two sites visited.

Conclusion

This evaluation demonstrated the value of a peer-review process to offer a multidimensional, external but friendly assessment of a CBE programme. The process provided valuable insight and triggered institutional commitment and motivation to revise and align the curriculum with the intended goals. Regular evaluation of CBE activities is critical to ensure that educational goals are being met and that limited resources for medical education are being used effectively to train a relevant workforce. Acknowledgements. We wish to acknowledge Ms Rebecca Bailey and the CapacityPlus team at IntraHealth International, who supported the planning and co-ordination of the peer-review visit and were part of the initial conceptualisation of the project. We thank the staff, students and clinical preceptors of the University of Zimbabwe for their participation in the peerreview process. Author contributions. DM: co-facilitated the peer-review project, contributed to the analysis, conducted the write-up of the project results and wrote the manuscript. IC: facilitated the peer-review project, was involved in the concept and design of the process, contributed to the data analysis and made substantial critical revisions to all drafts of the manuscript. MSM: peer reviewed the project, contributed to the data analysis and made critical revisions of the manuscript. JGH: principal investigator on the UZCHS MEPI project, and involved in the

conception and design of the process, as well as critical evaluation of the draft manuscript. ZT: member of the project management team and made substantial contributions to the interpretation of the data, as well as editorial revision of the manuscript. MHM: peer reviewed the project, and contributed to the data analysis and critical evaluation of the draft manuscript. MMC: principal investigator of the project, involved in its conception and design, as well as in critical evaluation of the draft manuscript. AM: on-site project co-ordinator and responsible for pre-visit data collection, as well as contributing to the review of the manuscript. MS: peer reviewed the project, and contributed to the data analysis and critical evaluation of the manuscript. All authors approved the final submitted version of the article. Funding. Funding was received from the CapacityPlus project within IntraHealth International. Conflicts of interest. None.

1. Mariam DH, Sagay AS, Arubaku W, et al. Community-based education programs in Africa: Faculty experience within the Medical Education Partnership Initiative (MEPI) network. Acad Med 2014;89(8):S50-S54. https://doi. org/10.1097/ACM.0000000000000330 2. Chen L, Evans T, Anand S, et al. Human resources for health: Overcoming the crisis. Lancet 2004;364(9449):19841990. https://doi.org/10.1016/S0140-6736(04)17482-5 3. Reid S, Cakwe M; on behalf of Collaboration for Health Equity through Education and Research (CHEER). The contribution of South African curricula to prepare health professionals for working in rural or underserved areas in South Africa: A peer review evaluation. S Afr Med J 2011;101(1):34-38. https://doi.org/10.7196/ SAMJ.4526 4. Michaels DC, Reid SJ, Naidu CS. Peer review for social accountability of health sciences education: A model from South Africa. Educ Health 2014;27(2):127. https://doi.org/10.4103/1357-6283.143728 5. Tsikirayi CMR, Todd CH. Community-based medical education and curriculum change: The field attachment programme of the school of medicine of the University of Zimbabwe. Ann Comm-Oriented Educ 1992;6:4-52. 6. Boelen C, Woollard R. Global consensus for social accountability of medical schools. 2010. http://healthsocialaccountability.org/ (accessed 26 July 2017). 7. 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. https://doi.org/10.1016/S01406736(10)61854-5 8. Couper I, Sen Gupta T, McInerney P, Larkins S, Evans R. Transforming and scaling up health professional education and training: Policy brief on faculty development. http://whoeducationguidelines.org./sites/default/ files/uploads/whoeduguidelines_PolicyBrief_FacultyDevelopment.pdf (accessed 26 July 2017). 9. Mayer RE. Applying the science of learning to medical education. Med Educ 2010;44(6):543-549. https://doi. org/10.1111/j.1365-2923.2010.03624.x 10. Levinson AJ. Where is evidence-based instructional design in medical education curriculum development? Med Educ 2010;44(6):536-537. https://doi.org/10.1111/j.1365-2923.2010.03715.x 11. Talib Z, Kiguli-Malwadde E, Wohltjen H, Derbew M, Mulla Y. Transforming health professions’ education through in-country collaboration: Examining the consortia between African medical schools catalyzed by the medical education partnership initiative. Hum Resources Health 2014;13(1):1. https://doi.org/10.1186/14784491-13-1 12. Chen C, Buch E, Wassermann T, et al. A survey of Sub-Saharan African medical schools. Hum Resources Health 2012;10(1):4. https://doi.org/10.1186/1478-4491-10-4 13. 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. https://doi.org/10.1111/j.1365-2923.2011.04039.x 14. Zimbabwe National Statistics Agency. Census 2012 Report, Zimstat, Harare, Zimbabwe. 2013. www.zimstat. co.zw/ (accessed 26 July 2017). 15. Wilson NW, Couper ID, de Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health 2009;9(2):1060. 16. Strasser RP. Community engagement: A key to successful rural clinical education. Rural Remote Health 2010;10(1543):1-8. 17. Couper I, Hugo J, Conradie H, Mfenyana K. Influences on the choice of health professionals to practise in rural areas. S Afr Med J 2007;97(11):1082-1086. 18. Michaels D, Couper I. Guide for conducting peer reviews of community-based health sciences education programs: CapacityPlus. 2015. https://www.capacityplus.org/files/resources/cbe-peer-review-guide-final.pdf (accessed 26 July 2017).

Accepted 5 March 2017.

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Research

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

Fifth-year medical students’ perspectives on rural training in Botswana: A qualitative approach P Kebaabetswe,1 PhD, MPH; T Arscott-Mills,2,3,4 MD, MPH; K Sebina,1 BSc; M B Kebaetse,1,5 PhD; O Makgabana-Dintwa,1 MPH; L Mokgatlhe,6 PhD; G Tawana,1 BSc; D O Mbuka,7 MD, MMed Fam Med; O Nkomazana,1,8 MB ChB, FCOphth, MSc CEH 1

Medical Education Partnership Initiative (MEPI), Faculty of Medicine, University of Botswana, Gaborone, Botswana

Botswana-University of Pennsylvania (Botswana-UPenn) Partnership, Gaborone, Botswana

Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, PA, USA

Department of Paediatrics, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Department of Medical Education, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Department of Statistics, Faculty of Social Sciences, University of Botswana, Gaborone, Botswana

Department of Family Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana

Corresponding author: T Arscott-Mills (tonyaarscottmillsbup@gmail.com)

Background. The curriculum of the Faculty of Medicine at the University of Botswana includes rural community exposure for students throughout their 5 years of training. In addition to community exposure during the first 2 years, students complete 16 weeks of family medicine and 8 weeks of public health medicine. However, as a new faculty, students’ experiences and perceptions regarding rural clinical training are not yet known. Objective. To describe the experiences and perceptions of the 5th-year medical students during their rural training and solicit their recommendations for improvement. Methods. This qualitative study used face-to-face interviews with 5th-year undergraduate medical students (N=36) at the end of their family medicine rotation in Mahalapye and Maun villages. We used a phenomenological paradigm to underpin the study. Voice-recorded interviews were transcribed and analysed using Atlas TI version 7 software (USA). Results. Three main themes were identified: (i) experiences and perceptions of the rural training environment; (ii) perceptions of the staff at rural sites; and (iii) perceptions of clinical benefits and relevance during rural training. While the majority of students perceived rural training as beneficial and valuable, a few felt that learning was compromised by limited resources and processes, such as medical equipment, internet connectivity and inadequate supervision. Conclusion. While the majority of students perceived rural training as beneficial, students identified limitations in both resources and supervision that need to be improved. Understanding students’ rural training experiences and perceptions can help the Faculty of Medicine, stakeholders and site facilitators to guide future rural training implementation. Afr J Health Professions Educ 2017;9(3):144-147. DOI:10.7196/AJHPE.2017.v9i3.738

Many medical schools currently offer medical students the opportunity to spend time in rural settings as part of their education.. The expectation is that such experience will encourage future interest in rural practice. This approach is supported by studies showing that rural experiences during training can increase the likelihood of students choosing to practise in rural areas after graduation.[1-3] The first medical school in Botswana opened at the University of Botswana in 2009 and the first cohort of students graduated in 2014. The school trains doctors in Gaborone, an urban setting, with rural clinical placements in Serowe, Molepolole, Mahalapye and Maun. The teaching curriculum emphasises that the training should take place at all levels of the health system; therefore, the curriculum includes rural training to enhance students’ learning and experiences. The curriculum includes exposure to rural healthcare in various formats throughout the 5-year programme. The places where students do rural training are highlighted in Fig. 1. During each of the 1st and 2nd years

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students complete 4 weeks’ training in a public health community, in each of the 3rd and 5th years they complete 8 weeks of family medicine, and in the 4th year they complete 8 weeks of public health. This gives a total of 32 weeks of rural exposure throughout the 5 years. As an example, the curriculum for the family medicine rotation involves problem-based learning sessions, ward rounds and outpatient care, as well as attendance at continuing medical education lectures. Tutorials and practicals focus on patient-centred consultations, the doctor, the patient and environmental factors in consultation, communication skills (e.g. breaking bad news), motivational interviewing and counselling skills. Although the medical students in Botswana are exposed to rural training at different levels, their perceptions of the current rural training are unknown. Exploring students’ rural experiences and perceptions of the clinical rural training relevance is important to a newly established school. Understanding their experiences and perceptions can help the Faculty of Medicine to improve future rural development and maximise

Research right to be interviewed in either of the two languages. Most preferred to mix Setswana and English. The data collection tool included demographic information and a structured open-ended interview guide (Table 1). Although the questions were not piloted with students, they were reviewed by independent persons, who provided feedback on understanding. Data were collected by three researchers (OMD, GT and KS), with no teaching or clinical interactions with students. Participants were encouraged to openly express their views about rural training. To facilitate data capturing, the interviews were audio recorded after consent had been obtained. The duration of an interview was up to 1.5 hours. Although data saturation was Legend: rural site reached aftertraining 12 interviews, all 15 interviews with individual participants were included in the analysis. Following data collection, interviews were transcribed and translated by two independent professional transcribers.

Data analysis

Rural training site Fig. 1. Map of rural training sites.

students’ learning experiences. This article focuses on the experiences and perceptions of 5th-year medical students after completion of the 32 weeks of their rural exposure. The specific objective of the study was to describe the experiences and perceptions of 5th-year medical students during their rural training and solicit their recommendations for improvement.

Methods

Between October 2013 and June 2014, we conducted an open-ended interview qualitative study among 5th-year medical students after their 8-week family medicine rotation. Interviews were conducted at the training sites of the Faculty of Medicine, University of Botswana, in Mahalapye, Maun and Gaborone. We used the phenomenological paradigm to underpin the study, as this approach is relevant for formulating the experiences and perceptions of individuals from their own perspectives.[5]

Participants’ recruitment

All 36 (16 female, 20 male) 5th-year undergraduate medical students were invited to participate in the study during the last week of their 8-week family medicine rotation. Criteria included having completed the 5th-year rural training rotation at one of the four rural clinical placement sites. Recruitment was done by email; all 5th-year students were informed of the study and were followed up by means of telephone calls inviting them to take part. Of 36 potential 5th-year students recruited, 15 accepted the invitation and 21 declined, citing a busy schedule.

Data collection

Data were collected from the 15 students who volunteered to take part in the study. After informed consent was obtained, they participated in a face-toface interview at a place and time convenient to them. The interviews were conducted in either Maun or Mahalapye during the last week of the rotation, or in Gaborone after they returned from the rural rotation sites. Although all medical students were fluent in both Setswana and English, they had the

Content data analysis was performed by three researchers (PK, OMD and GT). The team thoroughly read and re-read each transcript, and listened back to the audio-recorded interviews to become familiar with the data and to check all transcripts for errors. The team used the Atlas TI version 7 software (USA) to code and identify common themes and subthemes independently. They discussed their analysis and reached a consensus on the key themes and interpretations.

Ethical considerations

Ethical approval was obtained from the ethics committees of the University of Botswana (ref. no. UBR/IRB/1454), the Ministry of Health, Botswana (ref. no. PPME 18/8/1 VIII (303), and the University of Pennsylvania, PA, USA (ref. no. 81944). Because of confidentiality, the names of the participants were not written on the interview guide and not used during audio recordings. The tape recordings were locked and kept by the principal investigator. Signed consent was kept locked separately from the data and recordings.

Results

Three main themes were identified: (i) experiences and perceptions of the rural training environment; (ii) perceptions of the staff at rural sites; and (iii) perceptions of clinical benefits and relevance during rural training.

Experiences and perceptions of the rural training environment Students expressed mixed views about the rural training environment. While some claimed that, in general, the rural environment was more relaxed, less hectic and less conducive to learning, others felt that rural areas lacked resources such as simple medical equipment and internet connectivity and were therefore not conducive to learning. Presented below are examples of both positive and negative perceptions. Table 1. Interview guide Demographic information • Please tell me about your rural training experiences. Probe for: rural training environment, the staff and facilities • In your opinion, was the rural training or exposure during your medical school training beneficial/valuable or not? Please explain your answer • What challenges, if any, did you encounter during your rural training? How do you think they can be improved? What are your recommendations?

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Research Positive perceptions ‘I got to see something different from what I was used to seeing at Princes Marina in Gaborone. For the first time I got to work where it wasn’t really, really busy, so there was time to focus on one patient at a time and just learn from that and establish a working relationship, so that was good.’ (Participant 3) ‘I enjoy the rural environment to some degree; enjoy the relaxed nature of most of the places. Also just being in a different environment is something that I have also enjoyed. I tend to have time to even study for other things, yes. It’s not very hectic like when I’m in Gaborone.’ (Participant 13) Negative perceptions ‘When you have no equipment, no basic things like an ECG machine and you have a patient who has arrhythmias and you don’t have an ECG machine you end up compromising medical. If you need to do a CT on a patient you don’t need to send the CTs or the samples anywhere further, you get the results as soon as possible.’ (Participant 4) ‘I think rural environment kind of delays professional growth because if there are no supplies and no equipment then I won’t be able to help as much as I know I could help. But having been placed here for the past seven weeks, I don’t think I have learnt as much as I would have learnt when I was in Gabs. I want a place where I can be challenged every day and that will help me grow professionally.’ (Participant 10)

Perceptions of the staff and community at rural sites

Generally, almost all the students felt that people in the rural sites were welcoming and supportive, including those at the hospitals, at the clinics and in the community. ‘Generally the people were very welcoming. They respected us more and appreciated us more and they welcomed us more than in the urban setting and even in the hospital people work together and respect each other. Even the community members they respect us, they really appreciate us and welcomed us here and even appreciate us as Batswana doctors.’ (Participant 1) ‘Generally the people were very welcoming. It was, it felt … warm to be there. The people in the hospitals … the people just in the town … yeah, cause I was in Maun. They were very excited, very happy and helpful. I thought that was nice, yes. It would definitely be good to work in that kind of environment, everyone was helpful, even in the hospital.’ (Participant 11)

Perceptions of clinical benefits and relevance during rural training Students had different views about clinical benefits and the relevance of rural exposure. The majority of students described the rural training as clinically beneficial and valuable, as it offered them the opportunity to apply theoretical knowledge, gain practical skills, learn new cases in a relaxed environment, and appreciate cultural influences on diseases. Students with negative experiences felt that there were fewer opportunities for learning. They only saw uncomplicated cases because serious ones were referred to city hospitals. Others expressed concerns that there were fewer opportunities for professional growth, as there were few specialists to learn from and shortages of equipment to provide quality care, as well inadequate supervision. Positive perceptions ‘Rural training is advantageous for me because it widens my scope of learning. I think I learnt much more … varied content of stuff in a rural

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setting than … in a referral hospital where I just focused on surgical cases, but in rural areas there are different things that come on the same day, and its better … .’ (Participant 8) ‘I think rural rotations are beneficial in the sense that you really get to see different things … you get to see different … ways that could work and you get to be in a different setting and you get experience. It was a nice experience because I managed to see how culture actually influences diseases so it was nice to see how their culture influences their health around there.’ (Participant 13) ‘In the rural areas, there are opportunities to practise procedures. So there is not much competition in terms of procedures here. But you go to Marina you compete with third-year medical students, fourth-year and interns that’s the problem. I have learnt a lot. Even my experience to actually assist in an operation was in a rural environment which I enjoyed very much.’ (Participant 15) Negative perceptions ‘Having been exposed to a rural area I realised that actually being in an urban area is way better because there you have all the equipment that you need. You know if you need to do a CT on a patient you don’t need to send the patient out of the city.’ (Participant 4) ‘… having been placed here for the past seven weeks, I don’t think I have learnt as much as I would have learnt when I was in Gaborone; the quality is low. Actually I think rural areas kind of delayed my professional growth.’ (Participant 10) ‘There was no teaching during the rural/family medicine rotation; everyone was on their own, unlike in Marina where there are many mentors. I do not think it was beneficial to learning, we just go to hospitals, little learning during morning rounds, then morning meetings, rest of the day you are on your own.’ (Participant 1)

Discussion

Rural training has been found to provide a valuable opportunity to develop skills, competencies and confidence in the management of patients with various conditions.[6-8] The literature also suggests that rural training programmes can have a positive effect on patient care.[9] Additionally, Smith[10] indicates that rural training can have a positive influence and impact on medical students and residents and dispel misconceptions of rural healthcare practices. Consistent with the literature, our findings showed that the majority of students had positive experiences during rural training. They claimed that their learning was enhanced by a relaxed and less hectic rural work environment. In view of the benefits of rural exposure, students’ supervision during rural training is important to maximise positive experiences. The quality of students’ supervision during field placements is related to overall student satisfaction.[11,12] In a study to explore undergraduate medical students’ satisfaction with faculty support supervision during community placements in Uganda, Mubuuke et al.[13] noted that lack of resources to manage frequent supervision visits to the students while they were in the communities and few available faculty supervisors were key challenges to students. Similarly, our study showed that students experienced inadequate supervision owing to a shortage of clinical staff, which affected learning. As a solution they recommended that rural medical doctors be empowered to supervise undergraduate students during rural training. This model has been supported in the literature.[13] Limited resources can contribute to a dislike of rural exposure.[14] Although rural training is usually done in places with limited resources,

Research absence of the internet and web-based support has been found to increase students’ perception of academic isolation.[15] Our results showed that limited resources contributed to negative rural experiences. Students recommended that in future rural training sites should be equipped with adequate resources and facilities, such as electricity, water, television and internet. Although students decried limited resources at rural training sites, interestingly, some felt that the rural areas were not rural enough and they would have preferred exposure to the most remote areas to prepare them for worse experiences in their medical career. When selecting rural training sites it is important to select those that could maximise experiences, while ensuring that the learning environment is optimised.

Conclusion

The general experiences and perceptions of 5th-year medical students were positive. While the majority perceived rural training as beneficial, students also identified barriers related to both resources and supervision that need to be improved. These results can be used by the university, stakeholders and site facilitators to enhance students’ rural experiences and guide future rural training implementation.

Study limitations

Although issues raised in our study are consistent with findings in other studies, the results are specific to Botswana students. They cannot be generalised to all medical students and it is possible that the students who did not participate would have different views. However, recommendations could be applicable to other similar settings in the region. Although the interviews were conducted by staff not directly involved with the students, it is possible that some students declined to participate because all the interviewers were university staff. Acknowledgements. The information, content and conclusions presented in the article are those of the authors and should not be construed as the official position or policy of, and endorsements should not be inferred by, the Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS), or US government.

Author contributions. PK: planning, design of data analysis, and writing of the manuscript. TAM: planning, design and implementation of the study, and editing of the manuscript. OMD: planning, design and data collection, data analysis, and editing of the manuscript. GT: data collection and editing of the manuscript. KS, MBK, DOM, LM and ON: planning and editing of the manuscript. All authors approved the final version of the manuscript. Funding. This study was supported by the HRSA, and the US Department of HHS, grant T84HA22125 (Medical Education Partnership Initiative, US$10 000 000). Conflicts of interest. None.

1. Tate RB, Aoki FY. Rural practice and the personal and educational characteristics of medical students: Survey of 1 279 graduates of the University of Manitoba. Can Fam Phys 2012;58(11):e641-e648. 2. Farmer J, Kenny A, McKinstry C, Huysmans RD. A scoping review of the association between rural medical education and rural practice location. Hum Resource Health 2015;6(13):27. https://doi.org/10.1186/s12960-0150017-3 3. Holst J, Normann O, Herrmann M. Strengthening training in rural practice in Germany: New approach for undergraduate medical curriculum towards sustaining rural health care. Rural Remote Health 2015;15:3563. 4. Botswana villages. https://www.google.co.bw (accessed 20 October 2016). 5. Davidsen AS. Phenomenological approaches in psychology and health sciences. Qual Res Psychol 2013;10(3):318339. https://doi.org/10.1080/14780887.2011.608466 6. Irlam J, Pienaar L, Reid S. On being agents of change: A qualitative study of elective experiences of medical students at the Faculty of Health Sciences, University of Cape Town, South Africa. Afr J Health Professions Educ 2016;8(1):41-44. https://doi.org/10.7196/AJHPE.2016.v8i1.540 7. Van Schalkwyk SC, Bezuidenhout J, Conradie HH, et al. ‘Going rural’: Driving change through a rural medical education innovation. Rural Remote Health 2014;14:2493. 8. Kibore MW, Daniels JA, Child MJ, et al. Kenyan medical student and consultant experiences in a pilot decentralised training program at the University of Nairobi. Educ Health (Abingdon) 2014;27(2):170-176. https://doi.org/10.4103/1357-6283.143778 9. Liskowich S, Walker K, Beatty N, Kapusta P, McKays, Ramsden VR. Rural family medicine training site: Proposed framework. Can Fam Phys 2015;61(7):e324-e330. 10. Smith CC. Investigating a rural immersion experience in medical education utilizing narrative inquiry. Narrative Inquiry Bioethics 2012;2(1):55-64. https://doi.org/10.1353/nib.2012.0005 11. Barrett FA, Lipsky MS, Lutfiyya MN. The impact of rural training experiences on medical students: A critical review. Acad Med 2011;86(2):259-263. https://doi.org/10.1097/ACM.0b013e3182046387 12. Roberts C, Daly M, Kumar K, Perkins D, Richards D, Garne D. A longitudinal integrated placement and medical students’ intentions to practise rurally. Med Educ 2012;46(2):179-191. https://doi.org/10.1111/j.13652923.2011.04102.x 13. Mubuuke AG, Oria H, Dhabangi A, Kiguli S, Sewankambo NK. An exploration of undergraduate medical students’ satisfaction with faculty support supervision during community placements in Uganda. Rural Remote Health 2015;15:3591. 14. Kapanda GE, Muiruri C, Kulanga AT, et al. Enhancing future acceptance of rural placement in Tanzania through peripheral hospital rotations for medical students. BMC Med Educ 2016;16(1):51. https://doi.org/10.1186/ s12909-016-0582 15. Isaac V, Watts l, Forster L, Mclachlab CS. The influence of rural clinical school experiences on medical students’ levels of interest in rural careers. Hum Resource Health 2014;12:48. https://doi.org/10.1186/1478-4491-12-48

Accepted 16 November 2016.

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Research

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

Quantity and quality of written feedback, action plans, and student reflections before and after the introduction of a modified mini-CEX assessment form R M Djajadi,1 MD, MMedEd; M Claramita,2 MD, MHPE, PhD; G R Rahayu,2 MD, MMedEd, PhD 1

Medical Education Unit, Faculty of Medicine and Health Sciences, Warmadewa University, Bali, Indonesia

Department of Medical Education, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia

Corresponding author: R M Djajadi (robinmartilo@gmail.com)

Background. Mini-clinical-evaluation exercise (mini-CEX) assessment forms that have been modified with the addition of specific spaces on separate sheets are expected to improve the quantity and quality of written feedback and the action plan for further learning which is agreed upon, and to encourage written reflection. Objective. To test whether the modified mini-CEX assessment forms improve the quantity and quality of the written feedback, action plan and student reflection in the mini-CEX assessment process. Methods. Data collection was conducted over 3 months. Data analysis used the c2 test to compare the quantity and quality of written feedback, action plans, and reflections before and after the introduction of a modified mini-CEX assessment form. Results. Twenty-four clinical teachers and 44 clinical students participated in this study. The percentage of written feedback increased by 39%, and the specificity increased by 30.1% (p=0.001). The percentage of written action plans increased by 37%, and the specificity increased by 17.7% (p=0.001). The percentage of written reflection in the new spaces on the modified forms reached 73%, and 49.2% were classified as ‘specific’. Conclusion. The use of modified mini-CEX assessment forms, with the addition of extra spaces on separate sheets, improved the quantity and quality of written feedback and action plans, and encouraged written reflection. Afr J Health Professions Educ 2017;9(3):148-152. DOI:10.7196/AJHPE.2017.v9i3.804

Background

The mini-clinical-evaluation exercise (mini-CEX) is a way of assessing the clinical performance of medical students.[1] The mini-CEX consists of three basic elements: a direct observation of the clinical performance of students; an assessment of clinical performance, based on components of competence; and a feedback session immediately after the observation.[1] Assessment based on direct observation of clinical performance, with feedback, has a strong impact on student behaviour and learning processes.[2,3] However, studies have found that the feedback given to students is inadequate.[4] Factors that have influenced the lack of provision of feedback are the ability of the teacher to provide feedback, the format of the assessment form (for written feedback) and the process of assessing and giving feedback.[3,5,6] Since the original emergence of the mini-CEX assessment, the form has included spaces to write feedback and an action plan for further learning.[1] The space for writing feedback is divided into two sections: areas that are positive (strengths), and areas that need to be improved (weaknesses). These spaces are found to be mostly unutilised.[7] The provision of written feedback and an action plan on the mini-CEX form is not satisfactory owing to the use of unspecific language, the format of the assessment form and uncertainty around the assessment process.[5] Moreover, the assessment process provides little ‘dialogue’ space between the teacher and the student. Efforts to use a modified mini-CEX form were therefore made to stimulate the provision of written feedback and reflection.[5]

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Unwritten or unspecific written feedback and action plan on the miniCEX form leaves unanswered questions as to how the feedback session went, and whether it really benefited the student’s learning process. The use of written feedback is important for evaluating the progress of a student based on written records/documents, and in the preparation of his/her portfolio.[8] Against this background, we tested whether a modified mini-CEX form, with the addition of specific spaces on separate sheets for feedback and action plan, and of a new section for written reflection, would improve the quantity and quality of the written feedback, action plan and student reflection in the mini-CEX assessment. Ethical approval for this study was obtained from the Medical Health Research and Ethics Committee (MHREC) at Gadjah Mada University (ref. no. KE/FK/953/EC).

Methods Design

This was a single-group pre-test-post-test quantitative study, comparing the data from previous mini-CEX forms and the data collected over 3 months after the introduction of the modified mini-CEX forms. The analysis was done by means of comparing the quantity and quality of the written feedback, action plan, and student reflection before and after the use of a modified form.

Research Participants

The participants were 24 clinical teachers and 44 undergraduate clerkship students who were on duty between 16 September and 15 December 2014 in the Departments of Obstetrics and Gynecology, Surgery, Internal Medicine and Paediatrics in Sanjiwani Hospital, Indonesia. In order to gain as much collectable data in the form of the mini-CEX sheets as possible, we purposely chose participants from those departments which had the longest period of rotation (3 months), and the highest number of students assigned at the time.

Instrument

The instrument used for collecting data was a modified mini-CEX form.[7] The original unmodified form was the regularly used mini-CEX form adapted from Norcini’s.[1] We then modified the mini-CEX form by adding specific spaces for feedback and reflection on each component of competence that was assessed. This modification was adapted from Pelgrim et al.’s[5] work on the mini-CEX form. The components of competence assessed in the mini-CEX form are as follows: (i) history taking; (ii) physical examination; (iii) professionalism; (iv) clinical judgement/diagnosis; (v) patient management; (vi) communication skills; (vii) organisation/ efficiency; and (viii) overall clinical care. Our modification was to include separate sheets for writing feedback, an action plan and student reflection. Sheet A, which refers to the components of competence assessed, is used for assessing student clinical performance. Sheet B, which contains specific feedback spaces for each component of competence, is used for writing feedback, and sheet C, which contains specific reflection spaces on each component of competence and space for an action plan, is a student reflection sheet. The modified mini-CEX form was then validated by two experts in medical education. The process of using the modified mini-CEX form was conducted based on the ‘reflective-feedback dialogue’ principle, as follows:[9] (i) students undertake clinical performances for the purposes of the mini-CEX, accompanied by a teacher; (ii) the teacher directly observes and assesses the student’s performance using sheet A; (iii) during the observation of the student’s performance, the teacher can write a short and specific feedback section on sheet B; (iv) after finishing the clinical performance, the student is given the opportunity to write a brief reflection on sheet C; (v) the teacher asks the student to present his/her reflection; (vi) the teacher provides oral feedback based on the feedback that has been written and based on student reflection; (vii) the teacher and student agree on an action plan based on learning goals, and the student writes this down briefly and specifically in the action plan space on sheet C; (viii) a follow-up should be planned to evaluate the achievements of the action plan at the next meeting; and (ix) the form is collected and placed in the portfolio document.

Procedures

Students are required to undergo mini-CEX assessments as a prerequisite for their being permitted to take the final examination on each departmental rotation. Each departmental rotation has a different schedule and different requirements about the number of mini-CEX assessments which must be performed. At the Department of Obstetrics and Gynecology, students must do two mini-CEX assessments, in weeks 5 and 7. The Department of Surgery requires three mini-CEX assessments, in weeks 3, 5 and 7. One mini-CEX is required in the rotation of the Department of Paediatrics, in

the last week before the final examination (week 12). The rotation in the Department of Internal Medicine also requires one mini-CEX assessment, which is conducted between weeks 8 and 10. The teachers who assess the mini-CEXes are decided on according to a fixed schedule, and cannot be specifically requested by students. Before data collection was carried out, we met all clinical teachers and undergraduate clerkship students to introduce the modified mini-CEX form. The length of the introduction session was ~20 - 30 minutes. It consisted of a brief description of the modified mini-CEX forms, and the steps to be taken to use them. We collected all unmodified mini-CEX forms from the mini-CEX assessments that had been done in the 3 months before the study began. Then we collected all of the modified mini-CEX forms used over the next 3 months. Once all the forms had been collected, the data transcription was carried out.

Data analysis

The amounts of written feedback, action plan and reflection were calculated by using the number of filled spaces on the form for each category as a percentage of the number of mini-CEX forms collected. The quality of the written feedback, action plan and reflection was determined according to specificity, where each variable was classified as belonging to one of three categories: specific, quite specific, or not specific. The specificity criterion for written feedback and written reflection was defined using the classification of Pelgrim et al.[5] The written material was classified ‘specific’ if it was clear which component was being referred to, which aspects of it were already positive v. which needed improvement, and why they were either considered good or needed to be improved. It was ‘quite specific’ if it only indicated which component was being referred to and what was already good about it v. what still needed to be improved. It was ‘not specific’ if only general aspects of the overall student clinical performance were covered, without indicating which components were really referred to in terms of what was already good and what needed to be improved. Similarly, the written action plans were classified using Pelgrim et al.’s [5] criteria as ‘specific’ if they showed explicitly which aspects of their clinical performance should be studied further; ‘quite specific’ if they only listed the components that should be corrected without giving further details; and ‘not specific’ when only general statements were made. Inter-rater reliability was tested with three other raters, who were students of a Master’s programme in medical education, using Cohen’s kappa test to ensure the validity of the classification made by the researcher. The raters were chosen based on their knowledge of mini-CEX assessments and feedback. The Cohen kappa-test results for the specificity classification of the written feedback, action plan and reflection between researchers indicated that there was agreement on the analysed variables (kappa values >0.6). P-values were calculated using the c2 test. The test was considered significant when p<0.05.

Results

The total number of unmodified mini-CEX forms collected between 16 June 2014 and 15 September 2014 was 78. The total number of the modified mini-CEX forms collected between 16 September and 15 Decem ber 2014 was 63.

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Research Written feedback

The amount of written feedback increased by 39.0%, and the amount of specific feedback by 30.1% (p=0.001), when the modified forms were used (Table 1). On the modified mini-CEX form, there are feedback spaces that are specific to each component assessed. If there was only one feedback comment on the assessed component that corresponded to the ‘specific’ criteria, then the overall feedback was classified as ‘specific’. An example of specific written feedback on the modified mini-CEX form is: The format of the interview already met/Preparation of the patient prior to the interview should be considered; ‘Generally good/observe patient reaction during examination; Already greets the patient and introduced himself/Maintain friendliness with the patient; Already good/(blank); (blank)/Need to understand again about termination of pregnancy; Already good/(blank); (blank)/ (blank); (blank)/(blank). (Sheet OB1B1).’ In this example, statements on the left of the ‘/’ indicate aspects of the clinical performance, such as history taking, physical examination, professionalism, patient management, communication skills, that are listed as strengths, while those to the right are aspects still considered deficient. It also considers what is good v. what is still lacking, and/or why it is good or still lacking, in ‘interview format (already met), the patient's reaction (during examination), (already) greets the patient, (maintain) friendliness, (need to understand again about) termination of pregnancy’.

Action plans

The percentage of written action plans increased on the modified forms by 37.0%, and specific action plans increased by 17.7% (p=0.001) (Table 2). In the example of a specific action plan, below, it is made explicit which aspects of clinical performance should be studied further: ‘Review the reason for induction in cases of oligohydramnion, the plan of putting a patient on a drip in the case of oligohydramnion; re-evaluate how to perform a physical examination of the Leopold manoeuver and VT [vaginal toucher] and how to calculate FHR [fetal heart rate].’ (Sheet OB6B3)

Written reflection

A total of 73% of the written reflection sheets had been used by the students to write reflections, while specific reflections made up 49.2% of the written reflection on the modified forms (Table 3). An example of a specific written reflection, again with strengths listed on the left and weaknesses on the right, is as follows: Detailed history/(blank); (blank)/Leopold examination, VT examination; greetings/(blank); (blank)/Indications for administration of oxytocin drip; Comprehensive/(blank); Good/(blank); Good/(blank); Good/(blank). (Sheet OB6B3)

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Table 1. The amount and quality of written feedback

Quality of feedback Blank Filled Not specific Quite specific Specific

Mini-CEX form type Unmodified (N=78), Modified (N=63), n (%) n (%) 49 (62.8) 15 (23.8) 29 (37.2) 48 (76.2) 21 (27) 14 (22.2) 3 (3.8) 11 (17.5) 5 (6.4) 23 (36.5)

p=0.001, significant if p<0.05.

Table 2. Action plan specificity in modified v. unmodified forms

Specificity Blank Filled Not specific Quite specific Specific

Mini-CEX form Unmodified (N=78), Modified (N=63), n (%) n (%) 71 (91) 34 (54) 7 (9) 29 (46) 1 (1.3) 5 (8) 5 (6.4) 12 (19) 1 (1.3) 12 (19)

p=0.001, significant if p<0.05.

Table 3. The specificity of written reflection Reflection Blank Filled Not specific Quite specific Specific

Modified mini-CEX form (N=63), n (%) 17 (27) 46 (73) 3 (4.8) 12 (19) 31 (49.2)

This example states which components are already good, and which are still deficient, such as history taking, physical examination, professionalism, patient management, communication skills. It also shows what is good v. lacking, and/or why this is so, in ‘detailed (history), Leopold (examination), VT (examination), greetings, indication for giving oxytocin drip’.

Discussion

The results of this study showed that the use of a modified mini-CEX form may increase the quantity and quality of teachers’ written feedback. The modified mini-CEX forms have spaces next to each component of competence to write feedback. These spaces can be used to capture written feedback, either specific or not. In the written feedback it can be assumed that the more specific the feedback, the more concerned the teacher was about this component. The mini-CEX was constructed to take into account the limited time that clinical teachers have while teaching and assessing students at the clinical bedside.[1] At first, after the introduction, most of the clinical teachers who participated in this study were reluctant to engage in the intervention because of the impression that it would give them more tasks and take up more of their time. However, we tried to reassure them that based on the process of using the modified mini-CEX form, the writing of feedback would be part of the student performance observation, which required no additional amount of time. The teacher would write

Research the feedback while doing the observation as part of usual procedure. Therefore, the modified mini-CEX form was not meant to be a burden, but should help the teachers remind themselves of their feedback statements that would be delivered at the end of the assessment. This written feedback could benefit the teacher as a reminder, if they had no time available to deliver the feedback right away. They could do the feedback session later based on the written feedback note. The results of this study also showed that the use of the modified miniCEX form increased the quantity and quality of the written action plans. These results are in accord with those of Haffling et al.,[6] who used the reflective-feedback dialogue principle in a structured assessment form. This study adapted the steps appropriate to the reflective-feedback dialogue principle, which require teacher and student to interact in order to reach conclusions, and thereby develop the action plan. The existence of this written action plan showed that there was interaction between teacher and student, resulting in agreement. Therefore, it can be concluded that the increase in the number of action plans developed that was seen in this study occurred because the steps used on the modified mini-CEX form can encourage teacher and student to interact better and to create a more specific action plan. This result proved that the use of the reflective-feedback dialogue principle on the mini-CEX assessment process was beneficial for encouraging interaction and thus improving the quality of the action plans developed. The modified mini-CEX form used in this study also includes a separate student reflection sheet that contains spaces to reflect on each component of competence. This reflection sheet serves to remind students to reflect after the clinical performance is complete. In addition, it also serves to remind them that there are things that must be communicated between student and teacher. The filled spaces for written reflections were used in 73% (n=63) of the forms, and 67% of these written reflections were classified as specific (31/46). This result is satisfactory, considering that the writing of reflections on the mini-CEX form was a first-time experience for the clinical students in this study. Note that reflection takes practice to make it a habit, which the use of these forms encourages. There was a possibility that the reflection data collected were written after performing the steps, i.e. outside of the mini-CEX duration, or after receiving feedback. This may have affected the result. However, according to Sargeant et al.,[10] reflection after receiving feedback can help a person in the process of deciding to accept or to reject the feedback. Therefore, despite this possibility of having written the reflections outside of the mini-CEX duration, it can still be concluded that in this study the use of the modified form encouraged and trained students to write reflections on their miniCEX assessment form. In the process of formative assessment, there are two aspects that may be reflected on: the performance itself, and the feedback provided after the performance.[11,12] Either reflection on the performance[13] or reflection on the feedback given[10] can be beneficial to the learning process. Therefore, it should be a point of consideration in the future in determining the use of the reflection sheet: that is to say, whether the reflection should be made only after receiving feedback, or before or after receiving feedback. The nature of the reflection that happened can be seen from the contents of the written reflections, which are able to demonstrate the strengths (aspects already good) and the weaknesses (things that need to be improved) of studentsâ&#x20AC;&#x2122; performance, and possible things that can be improved after the mini-CEX assessment. The existence of this reflection on experience indicates that

there has been a deep learning process.[12,14] We suggest that future research should elaborate on this issue of reflection. In this study, the use of a modified form led to an increase in the quantity and quality of the feedback and the action plans. However, it still can be questioned why the results have not been closer to 100%. There are several factors that affect the quantity and quality of the feedback and the action plans: factors involving the research subjects (communication skills and understanding of the feedback and the action plan) and factors related to conditions in the field (especially the duration of the mini-CEX). The research-subject factors play a more important role in determining the quantity and quality of the feedback and the action plan.[5] The mini-CEX duration factor also affects the quantity and quality of the feedback and the action plan. Presumably, the longer the duration of the mini-CEX assessment and feedback session, the greater the likelihood of having better quantity and quality of feedback and action plan. In this study, the mini-CEX duration factor was not controlled. Data were captured in real conditions that occur in the field, in terms of variations in the duration of the mini-CEX. This study may have been affected by the Hawthorne effect bias, in that the research subjects felt that they were being observed, inducing them to improve their performance. However, data on some subjects that undertook mini-CEX assessments several times within the 3 months showed that there were variations in the quantity and quality of the feedback. Some of the subjects remained consistent in providing written feedback, and some did not. This shows that the effect of an improvement in performance due to being observed was minimal. The long data collection period (3 months) also minimises this effect of being observed. This study used a small sample, but if we consider the proportion of the sample to the total population of teachers and students in the hospital, the sample is large. The number of research subjects in the clinical-teacher sample was 24 people, or 63% of the population (38 people). The number of research subjects in the clinical student sample was 44 people, or 38% of the population (115 people). The sample of clinical students in this study was not randomised, because we used the convenient sampling method, but considering that the distribution of the clinical rotation schedule for every department was already done randomly, this implies that the clinical students had already undergone a randomisation process. This study only considered four departments/laboratories, namely, obstetrics and gynaecology, surgery, internal medicine and paediatrics. This may affect the generalisability of the result to the whole undergraduate clerkship. The number of mini-CEX assessments performed in each rotation also varies, so that the amount of data collected from each research subject differed. Efforts to control the number of mini-CEX assessments conducted for research subjects in order for them to each have the same number is technically not feasible, and therefore we selected a period for comparison, i.e. 3 months before and after the intervention. We suggest that further research on these modified mini-CEX forms be carried out in different locations and settings.

Conclusions

From these results it can be concluded that the use of the modified miniCEX form, with the addition of specific spaces on separate sheets, improved the quantity and quality of written feedback and written action plans. It could also encourage and train students to write reflections on their clinical performance. Educational institutions could apply the use of the modified

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Research mini-CEX form to support the learning process of mini-CEX assessments. Data from the modified mini-CEX forms could be used for student portfolios, to monitor the development of the clinical-student learning process. Future studies are needed to assess user perceptions of using the modified mini-CEX form, and its relationship to the results of the next mini-CEX assessment or examination. Acknowledgements. The authors would like to thank the following individuals for their feedback on the article: Dr Efrayim Suryadi, Dr Yoyo Suhoyo and Dr Ova Emilia. Author contributions. RMD contributed to the design and implementation of the research, data collection, to the analysis and interpretation of the results and to the writing of the manuscript. Both MR and GRR supervised the project, gave feedback to the design and implementation of the research, interpretation of results and contributed to the final version of the manuscript. All authors provided critical feedback and helped shape the research, analysis and manuscript. Funding. This research received no grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflicts of interest. The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article.

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1. Norcini J. The mini clinical evaluation exercise. Clin Teach 2005;2:25-30. https://doi.org/10.1111/j.1743498X.2005.00060.x 2. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007;29:855-871. https://doi.org/10.1080/01421590701775453 3. Burch VC, Seggie JL, Gary NE. Formative assessment promotes learning in undergraduate clinical clerkships. S Afr Med J 2006;96:430-433. 4. Daelmans HEM, Overmeer RM, van der Hem-Stokroos HH, et al. In-training assessment: Qualitative study of effects on supervision and feedback in an undergraduate clinical rotation. Med Educ 2006;40:51-58. https://doi.org/ 10.1111/j.1365-2929.2005.02358.x 5. Pelgrim EAM, Kramer AWM, Mokkink HGA, Van der Vleuten CPM. Quality of written narrative feedback and reflection in a modified mini-clinical evaluation exercise: An observational study. BMC Med Educ 2012;12:97. https://doi.org/ 10.1186/1472-6920-12-97 6. Haffling AC, Beckman A, Edgren G. Structured feedback to undergraduate medical student: 3 years’ experience of an assessment tool. Med Educ 2011;33:e349-e357. https://doi.org/10.3109/0142159x.2011.577466 7. Djajadi RM. Jumlah dan Kualitas Umpan Balik dan Rencana Aksi Secara Tertulis Sebelum dan Sesudah Penggunaan Lembar Penilaian Mini-CEX dengan Penambahan Ruang Spesifik Umpan Balik dan Refleksi. Master’s thesis. Yogyakarta: Universitas Gadjah Mada, 2015. 8. Haffling AC, Beckman A, Pahlmblad A, Edgren G. Students’ reflections in a portfolio pilot: Highlighting professional issues. Med Teach 2010;32:e532-e540. https://doi.org/ 10.3109/0142159X.2010.509420 9. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ 2008;337:1292-1294. https://doi.org/ 10.1136/bmj.a1961 10. Sargeant JM, Mann KV, van der Vleuten, CP, Metsemakers JF. Reflection: A link between receiving and using assessment feedback. Adv in Health Sci Educ 2009;14:399-410. https://doi.org/ 10.1007/s10459-008-9124-4 11. Archer JC. State of the science in health professional education: Effective feedback. Med Educ 2010;44:101-108. https://doi.org/ 10.1111/j.1365-2923.2009.03546.x 12. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ 2009;14:595-621. https://doi.org/ 10.1007/s10459-007-9090-2 13. Pelgrim EAM, Kramer AWM, Mokkink HGA, et al. Reflection as a component of formative assessment appears to be instrumental in promoting the use of feedback: An observational study. Med Teach 2013;35:772-778. https://doi. org/10.3109/0142159X.2013.801939 14. Loughran J. Effective reflective practice: In search of meaning in learning about teaching. J Teach Educ 2002; 53:33-43. https://doi.org/10.1177/0022487102053001004

Accepted 5 March 2017.

Research

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

Upskilling nursing students and nurse practitioners to initiate and manage patients on ART: An outcome evaluation of the UKZN NIMART course R Mngqibisa,1 MB ChB, MPH; M Muzigaba,1 PhD, MPH, MPhil, BSc; B P Ncama,2 BCur, MCur, MBA, PhD; S Pillay,1 MB ChB, DOM, Dip HIV Man; N Nadesan-Reddy,1 MB ChB, FCPHM, MMed (Public Health Med) 1 2

Medical Education Partnership Initiative, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: R Mngqibisa (rmngqibisa@gmail.com)

Background. Currently, there is a need in South Africa to implement strategies to upskill nurses in the clinical management of HIV and AIDS, for effective and efficient management of people living with HIV. One such strategy is the nurse-initiated management of antiretroviral therapy (NIMART) course. Objectives. To evaluate the effectiveness of the NIMART course in increasing the knowledge of trainees in select clinical competencies, to assess whether perceived knowledge gain varied according to individual-level characteristics of trainees, and to determine trainee perceptions of the value and delivery of the course. Methods. A 5-day training course focusing on various areas of HIV was developed and delivered by experts in the field of HIV to multiple cohorts of fourth-year nursing students at the University of KwaZulu-Natal, and to post-basic nursing practitioners, over a 5-year period. A single-group pre- and post-quasi-experimental design was used to assess knowledge change and perceptions about the course among 1 369 trainees who had benefitted from the course during the implementation period. Results. Post-workshop test scores were significantly higher than pre-workshop scores (p<0.0001), based on both pooled and cohort-specific data. For pooled analysis, the pre-test median score was 67% (interquartile range (IQR) = 60% - 73%) and the post-test median score was 77% (IQR = 70% - 80%), with p<0.0001. The knowledge gain was the highest in respect of HIV prevention, followed by prevention of mother-to-child transmission, then HIV treatment and lastly, general knowledge of HIV. The vast majority were very satisfied with the content of the training, although 31.3% strongly disagreed that they were ready to apply the knowledge they had learned in their workplace. Conclusion. The training was generally well received, and improved the knowledge of participants in HIV and its management. However, this outcome represents short-term benefits of the programme, and there is a need for on-the-job mentorship and support in order to maximise on clinical outcomes related to HIV. Afr J Health Professions Educ 2017;9(3):153-158. DOI:10.7196/AJHPE.2017.v9i3.879

HIV/AIDS continues to be a global public-health problem. Globally, there are 36.7 million people living with HIV, 25.8 million of whom live in subSaharan Africa (SSA).[1] As of June 2015, 17 million people living with HIV were accessing antiretroviral therapy (ART), with 10.3 million of these accessing antiretroviral treatment in SSA. This is 54% of all people living with HIV in the region.[1] HIV/AIDS is also responsible for a large percentage of morbidity and mortality, especially in settings that have limited resources.[2] Of further concern is the fact that SSA was also home to 70% of all new HIV infections in 2012.[3] Compared with other countries in the world, South Africa (SA) has the highest number of people living with HIV and AIDS, and currently, the country has the largest public health antiretroviral therapy (ART) program me, which began in 2004[4,5] and is being received by about 3.4 million people.[1] With an estimated 6.4 million people living with HIV (PLHIV) in SA by mid-2012,[6] and increasing numbers of people requiring ART, treatment services need to be decentralised to ensure access and expansion of ART services. Barriers for the majority of South Africans needing healthcare,

such as poverty and the inability to travel long distances to access healthcare facilities, add to the critical need to decentralise HIV and AIDS care to primary healthcare settings.[7] Additionally, with the recent changes in eligibility criteria for ART initiation, and the resultant increase in the number of patients requiring antiretroviral (ARV) medication, a large pool of trained nurses will be required to initiate and manage patients requiring ART. In a recent media release published by the KwaZulu-Natal Department of Health (KZN DoH), the Provincial Health Member of the Executive Committee in KZN, Minister Dr Sibongiseni Dhlomo, announced that ‘the KZN DoH must urgently train many more nurses in the administering of antiretroviral treatment as SA adopts the World Health Organization’s progressive “test and treat” HIV guidelines.’[8] According to the same report, at the beginning of 2016, more than 1 700 nurses had been trained in nurseinitiated management of ART (NIMART) – a task-shifting strategy put in place in 2010 by the SA government to enhance care for PLHIV – but there remained a need to double this number by the end of 2016.[8] The NIMART strategy involves nurses initiating patients on ART, providing repeat prescriptions for patients stable on ART and appropriate

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Research referral to physicians as required.[9] Although there were still concerns about the ability of nurses to prescribe ART, some studies have reported equivalent treatment outcomes for patients treated by nurses to those managed by doctors.[10-13] Studies in SA have also reported similar outcomes, although some of these findings do not represent standard practice, as they are from sites/clinics heavily supported by non-governmental organisations and where intensive training and ongoing support of nurses was implemented.[11-14] A study from Cape Town showed that the responses of nurses to taskshifting varied from embracing it as a challenge capable of making their work more interesting, and increasing their knowledge and skills, to resisting it because of the additional workload without adequate support and training.[15] Koome et al., [16] in their study in Kenya, showed that the majority of nurses (70%, n=162) understood and supported task-shifting. Support for task-shifting increased with increased years of experience, and was strongly correlated to knowledge,[16] while support, supervision and training were seen by study participants as requirements for effective task-shifting.[17] Educational and occupational healthcare-worker training programmes have been shown to decrease fear and improve knowledge regarding HIV and AIDS transmission, and have led to the overcoming of negative attitudes and increased confidence and ability to care for PLHIV.[16] This article outlines the University of KwaZulu-Natal’s (UKZN’s) NIMART training model, designed to contribute towards the task-shifting and task-sharing strategy for better HIV treatment outcomes in SA. The article also presents results from a summative evaluation of the NIMART course, with a particular focus on the number and background of trainees who benefitted from the course from 2011 to 2015, and an assessment of the extent to which the course has improved the knowledge of trainees in the management of HIV-positive people. Trainee characteristics associated with knowledge change, and their perceptions about the delivery of the course, are also presented in this report. The NIMART course at UKZN was led by the Enhancing Care Initiative, and supported by a Medical Education Partnership Initiative (MEPI) grant. The course was launched at UKZN in 2011, and between 2011 and 2015, at least three separate courses were delivered each year. Each course lasted 5 days, and targeted both the fourth-year undergraduate nursing students and registered nurses who were already practising and doing post-basic and postgraduate programmes. The course focused on a number of topics related to the management of ART, and was taught by experts in the field of HIV and AIDS. The content covered during the 5-day course was complementary to the HIV content integrated into the curriculum. The course covered: (i) the basic science of HIV infection, including epidemiology, immunology and virology, and clinical aspects of HIV infection and AIDS; (ii) HIV management in adults and children, which includes opportunistic infections and their presentation and management; (iii) ART in adults and children, which includes classes of drugs and their modes of action; (iv) latest SA guidelines; (v) drug-related toxicities and their management, including treatment failure; (vi) HIV in women; (vii) HIV and TB comorbidity; (viii) ethics related to HIV and AIDS; and (ix) palliative care for PLHIV.

Methods Setting

This evaluation involved data collected at UKZN from NIMART participants who benefitted from the course during the period 2011 - 2015.

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Design

A single-group pre- and post-test quasi-experimental design was used to evaluate the extent to which training participants from different cohorts gained knowledge related to HIV clinical management. This type of study design has been widely used in estimating the effect of interventions on short-term outcomes, such as knowledge and attitudes, despite its limitations in alleviating a number of internal-validity threats such as selection bias and subject regression to the mean.[18] Change in knowledge was assessed by comparing pre- and post-test scores of NIMART trainees who received the training between 2012 and 2015. The data used for this analysis were therefore secondary data collected as part of outcome and process monitoring and scheduled evaluations of the NIMART course during this period. The assessment of trainee perceptions of the delivery and value of the NIMART course, as well as factors associated with perceived knowledge gain, involved cross-sectional analysis of pooled data collected from 2011 to 2015.

Ethical considerations

The dataset used for this evaluation was collected for the purposes of quality assurance for the MEPI programme. The dataset was obtained and used in robustly anonymised form, with all the identifying information removed. As the assessment of knowledge gain required paired analysis, pre- and post-test scores for individual trainees were supplied without names or unique identifiers which could be linked to participants’ details. A complete application for ethics approval was submitted to the UKZN Biomedical Research Ethics Committee, which granted ethics approval for this evaluation to be conducted (ref. no. BE035/15).

Participants

A non-probability sample that consisted of all 615 undergraduate nursing students, as well as 754 practising and post-basic nursing students, who benefitted from the NIMART course during the 2011 - 2015 course rollout period, was used. In total, 1 369 NIMART trainees were involved in this evaluation. All participants whose anonymised data were available in the programme monitoring records spanning the evaluation period (2011 2015) were considered for this evaluation.

Data collection

The data were collected from successive cohorts of learners who attended the NIMART course between 2011 and 2015. Three data-collection tools were used to collect these data. The first tool was a structured participantregistration form, which was used to collect information on the demographic and professional characteristics of NIMART trainees. The second tool was an anonymous knowledge-assessment questionnaire, which was completed by trainees before and after the course. This tool consisted of 30 ‘true or false’- and ‘don’t know’-type questions that represented key competencies for NIMART, including general knowledge of HIV/AIDS, knowledge of HIV treatment, HIV prevention and prevention of mother-to-child transmission (PMTCT) of HIV, to mention but a few. This tool was piloted in a sample of 15 participants, and evaluated for internal consistency using Cronbach’s alpha. Both positively and negatively worded questions were used, and the tool was given to all participants in each cohort of trainees to quantify their change in knowledge following the course. The third tool was a course-evaluation questionnaire, which collected information

Research

Data analysis

All the data were firstly processed in Excel 2010 (Microsoft, USA) and exported to Stata/IC 13.0 (StataCorp LLC, USA) and Tableau version 9.3 (Tableau Software, USA) for analysis. Trainee demographic and professional characteristics were summarised using frequency tables. The pre- and post-test scores and the score for perceived knowledge change were first inspected for normality using the Shapiro-Wilk and Shapiro-Francia tests. The distributions of the scores for perceived knowledge change across trainee demographic and processional characteristics were displayed using forest plots, with mean scores per group and 95% confidence intervals. The pre- and post-test scores were not normally distributed, and therefore the change in knowledge was assessed using the Wilcoxon signed-rank test for matched pairs. The distribution of scores before and after the training was displayed per cohort using a box plot with quantile plot overlays. This plot was chosen so as to show side-by-side quantile plots of cumulative distribution of pre- and post-test scores and their median, as well as the 25th and 75th percentiles. Traineesâ&#x20AC;&#x2122; satisfaction with the content of different NIMART thematic areas of training, as well as their perceptions of the value and delivery of the training, were summarised using a divergent bar graph. A p-value <0.05 was considered statistically significant.

Results

The Cronbach alpha tests carried out to assess the internal consistency of the study instrument revealed that the scales used in the instrument were reliable. The alpha coefficients for different sets of questions ranged between 0.78 and 0.86. A descriptive analysis of trainee characteristics revealed that by the year 2015, a total of 1 369 trainees from across the KZN province had benefitted from the programme, 87% of whom were female and 61% were working in healthcare facilities in rural KZN. The course uptake was highest among registered nurses (76.05%), compared with student nurses (12.37%), clinical nurse practitioners (8.68%), professional nurses (0.79%) and other nursing categories (2.11%).

Assessment of perceived knowledge change

From the mean percent scores presented in Fig. 1, it can be seen that Indian and white NIMART trainees believed that they gained relatively less knowledge than their coloured and black counterparts (p=0.084). However, these differences were not statistically significant. Candidates who came from facilities based in urban and peri-urban areas also believed that they gained relatively less knowledge from the training than their counterparts from rural areas (p=0.045), and male candidates believed that they learned more than females (p=0.726), as did professional nurses compared with student nurses (p=0.025). Similarly, participants who were in the last cohort believed they learned a lot more from the training compared with their colleagues in the preceding years (p=0.002). The mean score (89%)

was relatively high, which indicates that, on average, trainees believed they learned something from the training.

Assessment of actual knowledge change

Fig. 2 illustrates overall knowledge change among participants, across a number of competencies related to NIMART. Based on the median scores, it can be seen that the knowledge increase was consistent and statistically significant across all four training periods (p<0.0001). The median pre- and post-test scores were the highest in year 4 of the training programme. Fig. 3 depicts the changes in knowledge in four broad areas of the training course. The knowledge gain was the highest in respect of HIV prevention, followed by PMTCT, then HIV treatment, and lastly, general knowledge of HIV.

Perceptions of the course

Participantsâ&#x20AC;&#x2122; perceptions of the course were assessed based on 25 questions that represented different thematic learning areas of the course. The results from this assessment are presented in Fig. 4. Subgroup

..... n

Effect (95% CI)

p-value

Race Black Coloured Indian Other White

774 19 46 10 14

89.08 (88.17, 89.98) 93.16 (88.90, 97.41) 85.65 (81.91, 89.39) 93.00 (87.90, 98.10) 86.43 (77.33, 95.53)

0.084

Cohort 2012 2013 2014 2015

8 263 320 283

81.25 (67.67, 94.83) 88.02 (86.44, 89.60) 86.31 (84.90, 87.73) 93.20 (91.92, 94.48)

0.003

Gender Female Male

710 106

88.44 (87.49, 89.38) 89.25 (86.78, 91.71)

0.726

Geographical area where employed Urban Rural Peri-urban

122 307 87

86.15 (83.78, 88.51) 88.34 (86.95, 89.73) 85.80 (82.60, 89.01)

0.045

Profession Registered professional nurses Student nurses

195 48

87.59 (85.83, 89.35) 83.33 (78.65, 88.01)

0.025

Overall

874

89.01 (88.16, 89.86)

No.

pts

100

Mean score for perceived knowledge gain (%)

Fig. 1. A forest plot showing trainee perceived knowledge change in the management of ART following the training.

100

Year 1 (n=283)

Year 2 (n=281)

Year 3 (n=358)

Year 4 (n=209)

Median = 63 Median = 73

Median = 67 Median = 77

Median = 70 Median = 80

Pre-test Post-test

Wilcoxon p<0.0001

90 80 70

Test score (%)

on participantsâ&#x20AC;&#x2122; perceptions of the value and delivery of the course, their readiness for NIMART, their perceived knowledge change following the course and their satisfaction with the content of different NIMART thematic areas of training. This tool was also assessed for internal consistency using the Cronbach alpha test. The same three research instruments were used over the course of the evaluation period to ensure that measurements across cohorts of learners were standardised.

60 50 40 30 20 10 0 Wilcoxon p<0.0001

Fig. 2. Strip plot showing the cumulative distribution of test scores and median test scores before and after the training with significant tests: pooled data by year of training.

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Research Fig. 4. shows that, based on the pooled data, the vast majority of trainees who received NIMART training were very satisfied, or just satisfied, with the content of the training across all the 25 thematic areas of learning that they were asked to evaluate. A shown in Fig. 5, 31.3% of the NIMART trainees strongly disagreed that they would be able to apply the knowledge and skills that they

had learned from the training to their job upon returning to their workplace. Furthermore, 31% of trainees were not sure whether the use of case studies during their training was useful to their learning. However, the vast majority believed that the handouts given would be useful to them, and that the use of the examples during the training contributed to their understanding of the training content.

N=1133 General knowledge of HIV

PMTCT knowledge

Knowledge of HIV treatment

Knowledge of HIV prevention

50 40

Test score (%)

100

Test score (%)

100

Test score (%)

100

Test score (%)

100

50 40

Pre-test Post-test Wilcoxon p<0.0001

Fig. 3. Knowledge gain in specific thematic areas of learning related to nurse-initiated management of antiretroviral therapy competencies, pooled analysis (2012 - 2015). The pooled analysis, which combined data from all 4 years of assessment without considering different thematic areas of learning, also showed that knowledge increased significantly, with a baseline median score of 67%, which increased to 77% after the training (p<0.0001). The circles demarcate mean scores. PMTCT = prevention of mother-to-child transmission. Item

Average score

HIV and nutrition

4.5

0 2

Virology of HIV

4.6

0 1 6

Ethics and HIV confidentiality

4.6

0 2

Nurse practitioner assessment of the HIV-positive patient

4.6

00 5

Ethics and HIV informed consent

4.7

Monitoring for ART and treatment failure

65 67

27 18

73 68

27 17

4.7

11 4

Immune reconstitution inflammatory syndrome (IRIS)

4.7

11 5

HIV and TB

4.7

10 4

Common ARV drug toxicities

4.7

11 4

Palliative medicine in HIV and AIDS

4.7

0 2 5

Family planning

4.7

01 5

Screening for cervical cancer – Pap smear

4.7

013

Department of Health guidelines on HIV counselling and testing

4.7

013

Adherence strategies

4.7

013

Prevention of mother-to-child transmission guidelines

4.7

013

HIV and women

4.7

013

HIV infection in children

4.7

013

New sexually transmitted infection (STI) guidelines

4.7

00 4

Transmission dynamics, epidemiology and preventions, including STIs

4.8

00 3

Paediatric antiretroviral therapy treatment guidelines

4.8

00 4

Natural history and pathenogenesis of acute and chronic HIV

4.9

0 01

Adult antiretroviral therapy

4.9

0 01

Ethics and HIV

73 74

79 80

4.9

0 01

Staging of HIV

4.9

0 01

Opportunistic infections in adults

4.9

0 01

-10 -5

10 15 20 25 30 35 40 45 50 55 60

65 70

75 80

85 90 95 100

% Very unsatisfactory

Unsatisfactory

Neutral

Satisfactory

Very satisfactory

Fig. 4. Divergent bar graph showing trainees’ satisfaction with the content of different thematic training areas of the nurse-initiated management of antiretroviral therapy course: pooled analysis (2011 - 2015). Each thematic area of learning was measured on a 5-point Likert scale with values 1 - 5.

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Discussion Key findings

This evaluation indicated an overall improvement of knowledge regarding all aspects of HIV management among nursing students and postbasic and working nurses who attended the NIMART training between 2012 and 2015. When looking at specific thematic areas of learning, the pre- and post-knowledge scores were highest for PMTCT and HIV prevention, which might be due to the fact that nurses have been expected to demonstrate competencies around PMTCT and HIV prevention since the beginning of the ART programme in SA.[18,19] Therefore, their knowledge in these two thematic areas would be expected to be relatively high. The scores were lower with respect to general HIV knowledge and HIV treatment, which contrasts with the findings from a study conducted in India that showed high baseline and follow-up knowledge of HIV and its treatment.[20] Pooled results revealed relatively poor baseline knowledge (mean = 67). This may be related to inadequate learning among some trainees during their formative years, and limited exposure to the management of HIV-positive patients. Although not assessed in this evaluation – because the data were not available in the dataset used – it is hypothesised that baseline scores on objective measures of knowledge would have varied by professional characteristics and years of experience in the field. However, the evaluation focused on differences in knowledge according to when trainees received the training, and it was shown that both the baseline and post-test knowledge levels were better in the last group that benefitted from the training. This could be ascribed to the fact that by 2015, the majority of the nursing students were already benefitting from a curriculum which incorporated HIV, and the nurses were mostly from the facilities where NIMART was already being practised. In addition to the objectively measured knowledge gain, trainees were also asked to indicate the extent to which the course had benefitted them in terms of knowledge shift. The question asked them to rate, on a scale of 1% - 100%, how much they believed that their knowledge about HIV and its management had been impacted as a result of the NIMART course. Based on this assessment, it was determined whether their perception of the magnitude of knowledge change depended on their professional and demographic characteristics.

Research Item

Average score

I will be able to apply the knowledge and skills learned in this class to my job

3.7

The case studies added value to my learning

4.2

0 2

The scope of the material used in the training was appropriate to meet my needs

4.8

01 3

The examples presented helped me to understand the content of the training

4.9

00 1

The handouts will be useful on the job

4.9

00 2

-35

-30

-25

-20

-15

11 4

-10

-5

63 31

90 92 10

100

% Strongly disagree (1)

Disagree (2)

Neutral (3)

Agree (4)

Strongly agree (5)

Fig. 5. Divergent bar graph showing trainees’ perceived value of the nurse-initiated management of antiretroviral therapy training programme in their workplace: pooled analysis (2012 - 2 015).

Trainees from facilities based in urban and periurban areas reported less knowledge gain than their counterparts based in rural areas. This may be a proxy for superiority of knowledge at baseline, and may possibly be related to the fact that trainees in urban and peri-urban areas have better exposure to the management of HIV and possibly mentoring. It is therefore to be expected that they are likely to report less knowledge gain from the training compared with those in rural areas, who most likely have fewer support mechanisms around them to promote learning. Thus it may be correct to assume that more NIMART training is offered in urban/peri-urban areas than in rural areas, while the need for information may be greatest in the latter.

Recommendations

Pooled analysis also revealed that the median post-training score was 77%. For HIV treatment it was 75%, and 78% for PMTCT. It may be argued that these scores are not sufficient within the context of effective treatment of PLHIV and may suggest that didactic training alone is not adequate to capacitate or improve the ability of nurses to manage HIV. Training needs to be supported with continuous and ongoing mentoring, especially since only 63% of nurses felt confident enough to apply the knowledge and skills gained to manage PLHIV post training. This argument is supported by a study in Limpopo Province, SA, which showed that better knowledge was associated with frequency of training.[21] Another study by Cameron et al.[22] also argues that expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating more HIV-positive patients on ART. The baseline results on HIV clinical knowledge also highlight the need to create a strong foundation for nurses during their

formative years, so that they are equipped with the requisite competencies to effectively manage PLHIV. The nursing curricula in the various training institutions that are producing the next generation of nurses need to be structured to ensure that there is sufficient coverage of the essential elements of management of HIV, coupled with ongoing in-service training of nurses in the management of HIV, such as the NIMART programme. It is also recommended that a much more extensive study be carried out, to not only focus on the shift in knowledge related to HIV and its management, but also to track and trace NIMART trainees to establish whether they have implemented this knowledge in their workplaces, and to determine whether such an intervention has had an impact on an array of health outcomes. In SA, there is still a dearth of literature around the effectiveness of NIMART training in improving clinical outcomes. One study has, however, demonstrated that NIMART training can increase ART uptake and reduce workload at referral facilities, enabling doctors to concentrate on more complicated cases.[23] In their survey conducted in SA to assess whether nurses in primary-care clinics were initiating ART after attending NIMART training, Came ron et al.[22] showed that of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages.

Limitations

One of the limitations of this evaluation relates to the generalisability of the study findings. This is primarily because the study used a convenient sample of nurse practitioners and post-basic nurses who attended the NIMART

training course at UKZN during a specific period of time. However, the study does account for all the nursing students who were trained at UKZN during the evaluation period. Another limitation is that the study did not assess whether there were any differences between the nursing students and post-basic nurses and practising nurses in respect of baseline knowledge gain as well as actual knowledge shift. It would also have been valuable to show whether knowledge differed among practising nurses according to their level of experience in the clinical setting. This evaluation used secondary data, and these variables were not captured as part of primary data collection, and therefore could not be used in this study.

Conclusion

The UKZN NIMART training course has played a significant role in capacitating more than 1 300 nurses in KZN Province with NIMART skills, against the provincial target to double the number of NIMART-trained nurses from 1 600 by the end of 2016. This evaluation showed that the NIMART training programme can significantly increase knowledge of HIV and its clinical management among nursing students and nursing practitioners pursuing their post-basic training in the nursing field. The study showed that their baseline knowledge was low, and that perceptions about learning varied among trainees depending on their demographic and professional characteristics. Based on participants’ perceptions of how much knowledge shift they experienced from the course, it was evident that nurses from rural areas had the greatest need for the course. Despite the observed increase in knowledge, however, a certain proportion of trainees did not feel ready to implement the knowledge gained in their workplace, which suggests a need for an ‘on-the-

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Research job’ mentorship programme if the benefits of the programme are to be carried forward and be translated into positive health outcomes. Acknowledgements. This work was made possible by grant no. 5R24TW008863 from the President’s Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health, US Department of Health and Human Services. Its contents are solely the responsibility of the UKZN MEPI programme, and do not necessarily represent the official views of the government. The KZN Department of Health is also acknowledged for making the NIMART programme successful. Author contributions. RM, BN, SP and NN were involved in the development and roll out of the UKZN-NIMART programme, RM and BN led the implementation of the programme, MM and RM conceived the evaluation, MM conducted the study, and analysed the data, and MM, RM and BN drafted the manuscript for all co-authors to edit and sign off. Funding. This work was made possible by grant no. 5R24TW008863 from PEPFAR and the National Institutes of Health, US Department of Health and Human Services. Conflicts of interest. The authors declare no conflict of interest related to this work. 1. United Nations Programme on HIV/AIDS. Global AIDS update. Geneva: UN, 2016. http://www.unaids.org/ sites/default/files/media_asset/global-AIDS-update-2016_en.pdf (accessed 12 July 2016). 2. World Health Organization. Millennium Development Goals (MDGs). Fact sheet No. 290. New York: United Nations, 2015. http://www.who.int/mediacentre/factsheets/fs290/en/ (accessed 14 August 2016). 3. United Nations Programme on HIV/AIDS. Joint United Nations Programme on HIV/AIDS: UNAIDS Partnership with the Global Coalition on Women and AIDS (GCWA). Geneva: UNAIDS, 2010. http://www. womenandaids.net/About-GCWA/Partners-and-Members/Joint-United-Nations-Programme-on-HIV-AIDS%28UNAIDS.aspx (accessed 14 August 2016). 4. Health Systems Trust. Public HAART Projects in South Africa – progress to November 2004. Durban: Health Systems Trust, 2005. http://www.hst.org.za/publications/public-haart-projects-south-africa-progressnovember-2004 (accessed 14 August 2016). 5. Uebel KE, Timmerman V, Ingle SM, J van Rensburg DHC, Mollentze WF. Towards universal ARV access: Achievements and challenges in Free State Province, South Africa. S Afr Med J 2010;100(9):589-593. https:// doi.org/10.7196/samj.3897 6. Republic of South Africa. National Strategic Plan on HIV/STI and TB 2012 - 2016. Pretoria: South African National AIDS Council, 2011. https://www.health-e.org.za/wp-content/uploads/2014/12/SANAC-NSP-ProgressReport-2014.pdf (accessed 2 September 2016).

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7. Doshi RK, del Rio C, Marconi VC. Social determinants of HIV healthcare: A tale of two cities. In: Kasenga FY, ed. Understanding HIV/AIDS Management and Care – Pandemic Approaches in the 21st Century. Atlanta: Emory University School of Medicine and Rollins School of Public Health, 2011:34-58. 8. KwaZulu-Natal Department of Health. More nurses to be trained on nurse-initiated management of antiretroviral treatment (NIMART) programme to meet the expected high demand, following the adoption of new HIV ‘Test and Treat’ guidelines. Media release: KZN DoH. Pietermaritzburg: KZN DoH, 2016. http://www.kznhealth.gov. za/mediarelease/2016/NIMART-test-treat-guidelines-17052016.htm (accessed 1 December 2016). 9. Zuma J. Address by President Jacob Zuma on the occasion of World Aids Day, Pretoria Showgrounds, 1 Decem ber 2009. http://www.info.gov.za/speeches/2009/09120112151001.htm (accessed 17 March 2016). 10. Georgeu D, Colvin CJ, Lewin S, et al. Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: A qualitative process evaluation of the STRETCH trial. Implement Sci 2012; 7(66). https://doi.org/10.1186/1748-5908-7-66 11. Callaghan M, Ford N, Schneider H. A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health 2010;8(8):1-9. https://doi.org/10.1186/1478-4491-8-8 12. Shumbusho F, van Griensven J, Lowrance D, et al. Task shifting for scale-up of HIV care: Evaluation of nursecentered antiretroviral treatment at rural health centers in Rwanda. PLoS Med 2009;6(10):e1000163. https://doi. org/10.1371/journal.pmed.1000163 13. Cohen R, Lynch S, Bygrave H, et al. Antiretroviral treatment outcomes from a nurse-driven, communitysupported HIV/AIDS treatment program in rural Lesotho: Observational cohort assessment at two years. J Int AIDS Soc 2009;12(1):23. https://doi.org/10.1186/1758-2652-12-23 14. Uebel KE, Lombard C, Joubert G, et al. Integration of HIV care into primary care in South Africa: Effect on survival of patients needing antiretroviral treatment. J Acquir Immune Defic Syndr 2013;63(3):94100. https:// doi.org/10.1097/qai.0b013e318291cd08 15. Colvin CJ, Fairall L, Lewin S, et al. Expanding access to ART in South Africa: The role of nurse initiated treatment. S Afr Med J 2010;100(4):210-212. https://doi.org/10.7196/samj.4124 16. Centers for Disease Control. Recommended Prevention Services. Atlanta: Centers for Disease Control and Prevention, 2013. http://www.cdc.gov/hiv/prevention/programs/pwp/risk.html (accessed 10 August 2016). 17. Koome DI. Feasibility of task shifting in nursing practice: A case study of two level five public hospitals in Kenya. Kenya: University of Nairobi, 2012. http://erepository.uonbi.ac.ke/handle/11295/9328 (accessed 10 August 2016). 18. Shadish RW, Cook DT, Campbell DT. Experimental and Quasi Experimental Designs for Generalized Causal Inference. Boston: Houghton Mifflin Company, 2002. 19. Phetlhu DR, Watson MJ. Perceptions and attitudes of health workers towards patients co-infected with HIV and tuberculosis. J Soc Sci 2011;29(1):23-7. 20. Dicicco-Bloom B, Crabtree B. The qualitative research interview. Med Educ 2006;40(4):314-321. 21. Mulaudzi MV, Pengpid S, Peltzer K. Nurses’ knowledge, attitudes, and coping related to HIV and AIDS in a rural hospital in South Africa. Ethno Med 2011;5(1):25-32. 22. Cameron D. Nurse initiation and maintenance of patients on antiretroviral therapy: Are nurses in primary care clinics initiating ART after attending NIMART training? S Afr Med J 2012;102(2):98-100. https://doi. org/10.7196/samj.5195 23. Nyasulu JCY, Muchiri E, Mazwi S, Ratshefola M. NIMART rollout to primary healthcare facilities increases access to antiretrovirals in Johannesburg: An interrupted time series analysis. S Afr Med J 2013;103(4):232-236. https://doi.org/10.7196/SAMJ.6380

Accepted 15 November 2016.

CPD Questionnaire September 2017 True (A) or false (B): Health sciences students’ contribution to human resources for health strategy: A rural health careers day for grade 12 learners in the North West Province of South Africa 1. The participating learners reported that while they found the funding station informative, additional information on funding was needed. A quick needs assessment of key stakeholder groups on the role of family medicine in Zambia 2. There was general consensus among all respondents that there is a need for more family medicine physicians in Zambia. Registrar wellness in Botswana: Measuring burnout and identifying ways to improve wellness 3. According to the job demand-control-support model, employees who work in jobs with high demands, low control, and low social support experience the highest level of psychological and physical wellbeing. 4. The results showed that 75% of registrars had a high level of burnout, which is in the upper range of normal for registrars internationally. Assessment of the educational environment of physiotherapy students at the University of Rwanda using DREEM 5. The highest score was in the domain of ‘Students’ perceptions of learning’. Standardised patient-simulated practice learning: A rich pedagogical environment for psychiatric nursing education 6. The researchers noted that there is no evidence that using standardised patients decreases student anxiety and increases confidence. Understanding student early departure from a Master of Public Health programme in South Africa 7. Stress and demands of the MPH programme emerged as one of the main themes. Postgraduate trainees’ perceptions of the learning environment in a Nigerian teaching hospital 8. PHEEM has not been validated and is therefore not a reliable instrument. 9. Results showed no significant differences in scores across gender or specialty. Radiation safety requirements for training of users of diagnostic X-ray equipment in South Africa 10. According to the ICRP, the term training refers to imparting knowledge and understanding radiation health effects.

11. The Delphi technique involves a research team, who are involved collectively with the goal of enhancing the quality and utilisation of the research. Training requirements for the administration of intravenous contrast media by radiographers: Radiologists’ perspective 12. In South Africa, radiographers perform the task of administering intravenous contrast media as per their legal scope of practice. Perceptions of the impact of an advanced training programme on the management skills of health professionals in Gauteng, South Africa 13. Training of managers is not prioritised by the SA National Strategic Plan. 14. Respondents in this study scored poorly in the creation of a marketing plan and its implementation. A peer evaluation of the community-based education programme for medical students at the University of Zimbabwe College of Health Sciences (UZCHS): A southern African Medical Education Partnership Initiative (MEPI) collaboration 15. One of the strengths of the UZCHS curriculum is the consistent exposure of students to community-based education. 16. The entire process of peer evaluation happens over a short period of time and requires minimal commitment from hosts and reviewers. Fifth-year medical students’ perspectives on rural training in Botswana: A qualitative approach 17. This study was conducted using a survey to quantitatively analyse students’ perceptions of their rural training. 18. Consistent with other literature, the students in this study identified barriers of rural training relating to resources and supervision. Quantity and quality of written feedback, action plans, and student reflections before and after the introduction of a modified mini-CEX assessment form 19. The results of this study showed that the use of mini-CEX forms had no effect on the quantity and quality of teachers’ written feedback. Upskilling nursing students and nurse practitioners to initiate and manage patients on ART: An outcome evaluation of the UKZN NIMART course 20. Results showed that trainees from urban and peri-urban facilities report less knowledge gain than their counterparts in rural areas.

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September 2017, Vol. 9, No. 3 AJHPE