AJHPE Vol 9, No 4 (2017) by HMPG

African Journal of Health

Professions Education June 2017, 2017, December Vol. 9 Vol. No. 29, No. 4

Scholarship of Africa for Africa

ISSN 2078 - 5127

AJHPE African Journal of Health Professions Education December 2017, Vol. 9, No. 4

EDITORIAL

161 Scholarship for Africa: Are we taking it seriously enough? S van Schalkwyk

FORUM

162 The medical elective: A unique educational opportunity R I Caldwell, A C Inglis, M Morgan, K Rasmussen, C Aldous

SHORT RESEARCH REPORT

164 Selfies 2015: Peer teaching in medical sciences through video clips – a case study J D Pillay 168 The use of low-cost simulation in a resource-constrained teaching environment M Mwandri, M Walsh, J Frantz, R Delport

RESEARCH

171 Implementing the Angoff method of standard setting using postgraduate students: Practical and affordable in resource-limited settings A G Mubuuke, C Mwesigwa, S Kiguli 176 Medical students’ perspectives on the anatomy course at the University of Zimbabwe R Siwela, G Mawera

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 ASSOCIATE EDITORS Francois Cilliers University of Cape Town Rhena Delport University of Pretoria Patricia McInerney University of the Witwatersrand Ntombifikile Mtshali University of KwaZulu-Natal Anthea Rhoda University of the Western Cape Michael Rowe University of the Western Cape Marietjie van Rooyen University of Pretoria

180 Clinical undergraduate medical student training at Kimberley Hospital, Northern Cape, South Africa: ‘A test of fire’ S Joubert, V J Louw

Susan van Schalkwyk Stellenbosch University

185 Designing interprofessional modules for undergraduate healthcare learners C Maree, P Bresser, M Yazbek, L Engelbrecht, K Mostert, C Viviers, M Kekana

HMPG

189 Learning outcomes of occupational therapy and physiotherapy students during their community-based education attachment T Ndlovu, T M Chikwanha, N Munambah 194 Experiences of South African student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery L M Modiba 199 Self-leadership traits of academics to conform to a changing higher-education environment K Jooste, J Frantz 203 Clinical electives at the University of Michigan from the perspective of Ghanaian medical students: A qualitative study S Danso-Bamfo, N A Abedini, H Mäkiharju, K A Danso, T R B Johnson, J Kolars, C A Moyer 208 Factors that enable and constrain the internationalisation and Africanisation of Master of Public Health programmes in South African higher education institutions J Witthuhn, C S le Roux

CPD questionnaire

Elizabeth Wolvaardt University of Pretoria 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

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

HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Mrs H Kikaya, Dr M Mbokota, Dr G Wolvaardt ISSN 2078-5127

Editorial

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

Scholarship for Africa: Are we taking it seriously enough? In her 2009 inaugural editorial for AJHPE, Vanessa Burch[1] described the status of healthcare in Africa as being in a ‘desperate situation’ and argued that a response would be the strengthening and extending of existing training platforms, which, among others, would facilitate the emergence of a cadre of high-quality educators for the continent. It was into this space that she and her editorial team at the time envisaged a journal that would provide exposure for scholarship being produced in Africa. Such scholarship would speak to our unique context and challenges, and offer opportunities for both experienced and emerging educators to contribute to building a body of literature in health professions education (HPE). As I engaged with the different articles that comprise the final 2017 edition of AJHPE, 8 years after the first edition, I was struck by the depth and breadth of the work that is being showcased. It bears testimony to the way in which the journal has indeed become an important platform for scholarly endeavour in the field, and there is much to celebrate. It is clear that our research is not only keeping abreast of global trends, including innovative approaches to teaching with technology, strengthening assessment practices, and encouraging interprofessional approaches to education and collaborative care, but it is also responding to local imperatives in resourceconstrained contexts, often in creative ways. The student voice emerges strongly in these articles, and there is an interesting mix of methodologies being employed. The publications emanate from scholars located in both rural and urban contexts in Botswana, Ghana, South Africa, Uganda and Zimbabwe, and speak to undergraduate and postgraduate work, in the fields of human nutrition, medicine, nursing, occupational therapy, physiotherapy and radiography. Notwithstanding this positive picture, critical reflection as to the extent to which our work is influencing both our practice and thinking, and possibly also practice and thinking elsewhere in the developing world, is important. How has the scholarship that has been published in AJHPE over the past years contributed to transforming HPE, and to what extent has it been responsive to the challenges that Burch[1] posed for us at the genesis of the journal’s existence? Are we building on what others have done before us, and is this work finding traction in our classrooms and in our teaching? Of course, these questions are pertinent far beyond AJHPE. Van der Vleuten and Driessen[2] have previously challenged the sector to consider what HPE would look like if the evidence that is currently being generated was ‘taken seriously’. Would this be reflected in how we teach and how learning happens? In this edition of AJHPE, the evidence on offer takes various forms. Increasingly, for example, there have been calls to extend clinical training platforms beyond the traditional academic hospital. Joubert and Louw[3] describe how clinicians at these sites are experiencing and responding to this shift in practice. The distributed approach is also mirrored in many community-based education (CBE) initiatives. Ndlovu et al.[4] place the spotlight on opportunities for learning during a CBE attachment for occupational therapy and physiotherapy students in Zimbabwe. Another key theme from Maree et al.[5] relates to enhancing collaborative approaches to care, as curriculum developers grapple with designing responsive interventions. Continuity of care is the educational principle underpinning a course requirement for nursing science students, investi gated by Modiba.[6] Jooste and Frantz[7] explore the importance of academic leadership, particularly self-leadership, from the perspective of a group of senior academics from within and outside HPE. Their article offers insights into a complex set of preferred competencies for such leadership.

The medical elective features twice in this edition. While Caldwell et al.[8] discuss the elective as an opportunity for a unique educational experience, Danso-Bamfo and a group of international colleagues[9] qualitatively explore the experiences of Ghanaian students on an elective abroad. Several articles offer practical guidance for enhancing educational practices. The importance of reliability and validity in the assessment of student learning is addressed by Mubuuke et al.[10] Mwandri et al.[11] and Siwela and Mawera[12] employ statistical analyses to motivate for the use of a ‘low-cost’ approach to simulation-based training and innovative approaches to teaching anatomy, respectively. Pillay[13] picks up the potential of current technology and the use of ‘selfies’ to foster student engagement. Finally, current debates with regard to the need for radical curriculum transformation are problematised by Witthuhn and Le Roux,[14] specifically in the context of postgraduate studies in the arena of public health. Indeed, a rich matrix of perspectives and insights. Earlier this year, AJHPE changed its look and added the tagline: ‘Scholarship of Africa for Africa’. It is exciting to see how the research included in this edition embodies this ideal. Our ongoing endeavour should be to generate ever-more robust evidence to strengthen what we do. Either way, let’s be sure to take our work seriously.

S van Schalkwyk Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa scvs@sun.ac.za

1. Burch VC. Does Africa need another journal? Afr J Health Professions Educ 2009;1(1):2. 2. Van der Vleuten CPM, Driessen EW. What would happen to education if we take education evidence seriously? Perspect Med Educ 2014;3(3):222-232. https://doi.org/10.1007/s40037-014-0129-9 3. Joubert S, Louw VJ. Clinical undergraduate medical student training at Kimberley Hospital, Northern Cape, South Africa: ‘A test of fire’. Afr J Health Professions Educ 2017;9(4):180-184. https://doi.org/10.7196/AJHPE.2017.v9i4.836 4. Ndlovu T, Chikwanha TM, Munambah N. Learning outcomes of occupational therapy and physiotherapy students during their community-based education attachment. Afr J Health Professions Educ 2017;9(4):189-193. https://doi.org/10.7196/AJHPE.2017.v9i4.958 5. Maree C, Bresser P, Yazbek M, et al. Designing interprofessional modules for undergraduate healthcare learners. Afr J Health Professions Educ 2017;9(4):185-188. https://doi.org/10.7196/AJHPE.2017.v9i4.853 6. Modiba LM. Experiences of South African student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery. Afr J Health Professions Educ 2017;9(4):194-198. https://doi. org/10.7196/AJHPE.2017.v9i4.730 7. Jooste K, Frantz J. Self-leadership traits of academics to conform to a changing higher-education environment. Afr J Health Professions Educ 2017;9(4):199-202. https://doi.org/10.7196/AJHPE.2017.v9i4.823 8. Caldwell RI, Inglis AC, Morgan M, Rasmussen K, Aldous C. The medical elective: A unique educational opportunity. Afr J Health Professions Educ 2017;9(4):162-163. https://doi.org/10.7196/AJHPE.2017.v9i4.883 9. Danso-Bamfo S, Abedini NA, Mäkiharju H, et al. Clinical electives at the University of Michigan from the perspective of Ghanaian medical students: A qualitative study. Afr J Health Professions Educ 2017;9(4):203-207. https://doi.org/10.7196/AJHPE.2017.v9i4.827 10. Mubuuke AG, Mwesigwa C, Kiguli S. Implementing the Angoff method of standard setting using postgraduate students: Practical and affordable in resource-limited settings. Afr J Health Professions Educ 2017;9(4):171-175. https://doi.org/10.7196/AJHPE.2017.v9i4.631 11. Mwandri M, Walsh M, Frantz J, Delport R. The use of low-cost simulation in a resource-constrained teaching environment. Afr J Health Professions Educ 2017;9(4):168-170. https://doi.org/10.7196/AJHPE.2017.v9i4.829 12. Siwela R, Mawera G. Medical students’ perspectives on the anatomy course at the University of Zimbabwe. Afr J Health Professions Educ 2017;9(4):176-179. https://doi.org/10.7196/AJHPE.2017.v9i4.822 13. Pillay JD. Selfies 2015: Peer teaching in medical sciences through video clips – a case study. Afr J Health Professions Educ 2017;9(4):164-167. https://doi.org/10.7196/AJHPE.2017.v9i4.803 14. Witthuhn J, le Roux CS. Factors that enable and constrain the internationalisation and Africanisation of Master of Public Health programmes in South African higher education institutions. Afr J Health Professions Educ 2017;9(4):208-211. https://doi.org/10.7196/AJHPE.2017.v9i4.839

Afr J Health Professions Educ 2017;9(4):161. DOI:10.7196/AJHPE.2017.v9i4.1033

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Forum

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

The medical elective: A unique educational opportunity R I Caldwell,1 BSc (Med), MB ChB, FCP (SA), FRCP (Lond); A C Inglis,1,2 FACEM, FCEM (UK), MB ChB, Dip Soc Admin (Oxon), DTM&H (Liverpool), Dip Paed (AKL), Dip O&G (AKL), Dip Med Sci (Dive&Hyperbaric Med) (AKL); M Morgan,1,3 MB BCh, FCPaed (SA), Cert Critical Care (SA) Paed; K Rasmussen,1,3 FCP (SA), FCCH (SA), DHSM, DTM&H, DOH; C Aldous,1 PhD 1

School of Clinical Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa

KwaZulu-Natal Department of Health, Edendale Hospital, Pietermaritzburg, South Africa

KwaZulu-Natal Department of Health, Grey’s Hospital, Pietermaritzburg, South Africa

Corresponding author: R I Caldwell (ric@caldwells.co.za)

Elective medical student (EMS) programmes have existed worldwide for half a century and are voluntary placements undertaken as part of a medical degree, in a setting different from that to which the students are accustomed.[1,2] Electives take place at an early professional age, and provide in-depth experiences, including the core values of service learning. The community, students and medical schools should all benefit from this arrangement. Foreign students may choose South Africa (SA) for an international health elective (IHE) when their university affords them a period away from formal studies. The process involves advance paperwork and funding, whether through saving or by sponsorship.[3] The student applies via the recipient website, or directly to a particular consultant. Registration with the Health Professions Council of SA (HPCSA) is crucial, requiring confirmation of eligibility from the student’s own medical school and from the recipient SA school. Immunisation certificates, medical insurance, and provincial department of health indemnities are further necessities. Once fees are paid, the university will send a letter of acceptance. A tourist visa suffices if the visit is shorter than 3 months; otherwise, a study visa is required. Word-of-mouth information can result in a succession of IHEs to specific departments. When SA students, already HPCSA registered, seek electives at other SA hospitals, parent institutions only require an appropriate supervisor rather than acceptance by another medical school. There are also ‘non-elective’ applicants, i.e. SA citizens who, having not gained admission to a local medical school, are studying abroad. Their parent medical school requires a year’s clinical tuition in another country, including detailed documentation thereof. This is not a voluntary IHE, which merely requires a certificate of attendance.

Benefits of medical electives The student and the community

IHE students experience a different system of medicine in exotic surroundings, and are taken out of their comfort zones, observing the advantages and disadvantages of the foreign training. SA has patients with a wide range of illnesses that students overseas may not be exposed to. EMS programmes, embodying the concepts of person-centred and communityorientated care, allow these students to expand their knowledge base and skills under supervision. EMSs from SA universities will be able to observe how other medical professionals in the public health service deal with similar problems, thus acquiring a different approach to working in the developing world.

The recipient institution and medicine

Medicine is globalised, and therefore any gains to a student are to the credit of the recipient medical school.[4] This ‘bigger picture’ fits the mantra: ‘think globally, act locally’. IHE students, observing what developing countries deal

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with, may in time influence policymakers. They may provide insight into management of similar conditions in their own countries. Research is also a possibility. EMSs are popular with other medical personnel, as was obvious on rural outreach visits. There is evidence, both published and gained in person by three of the authors during outreach visits, suggesting that staffing of rural hospitals by foreign junior doctors is in accordance with IHEs.[5,6] These doctors, or their colleagues, had been EMSs as undergraduates, recommending hospitals noted for sound clinical experience under good supervision. No student should act unethically, e.g. by undertaking unsupervised clinical responsibilities beyond their level of capability.[7] SA medical school EMSs undertaking an elective elsewhere in SA might well consider internship, community service and beyond in the centre visited – a win-win outcome.

Drawbacks of IHEs/EMSs

There may be concern that EMSs could make undue demands on recipient consultants. However, the relevant department accepts such students only when it has the space and time for them. ‘Medical tourism’ has been criticised, as the net gain favours the trainee participant and insufficient consideration is given to the needs of the host country.[8] Nevertheless, the same authors acknowledge that even medical tourism increases involvement in global medicine.[8] EMSs come with a set of socially responsible objectives from their university. In our experience, most of them exceed the requirements and are anything but medical tourists.

Designing an EMS programme

While it is important not to over-regulate this fragile asset, administration needs to be efficient and user friendly. The following suggestions may be useful to institutions offering EMS and/or IHE programmes: • The elective experience should be based on international professional and ethical standards. • Potential EMSs should include a CV and details regarding their expectations from the elective. Preferred dates may be requested, up to a maximum of 16 weeks’ duration. • Applications should not proceed without a department’s acceptance of the EMS (automatically governing saturation). • University ‘processing’ should ensure that HPCSA registration takes priority; 3 - 4 months should suffice, with the onus on the student to complete the paperwork promptly. • EMSs from SA medical schools should not pay a fee, other than for accommodation. • Occupational health risks are real. An induction course in the first week is advisable, emphasising HIV- and tuberculosis-related issues.

Forum • The funds generated through IHEs could be used to enhance the programme, including sponsorship of local students for their own electives. Encouragement should be given to the institution’s own students towards undertaking elective periods, either as an IHE student or elsewhere in SA.

Conclusion

This article supports medical electives that benefit the community, the student and higher educational institutions. It identifies a ‘non-elective’ group, which needs attention. The objective is to provide an elective opportunity that will help to create 21st-century health professionals, including clinical involvement and encouragement towards enjoyment and appreciation of SA. Acknowledgements. None. Author contributions. All the authors complied with the International Committee of Medical Journal Editors' rules of authorship and were part of formulating and conceptualising the article. Although the initial draft was prepared by the first author, subsequent work on the manuscript included inputs from all authors.

Funding. None. Conflicts of interest. None. 1. Edwards R, Piachaud J, Rowson M, Miranda J. Understanding global health issues: Are international medical electives the answer? Med Educ 2004;38(7):688-690. https://doi.org/10.1046/j.1365-2929.2004.01849.x 2. O’Donnell P, McAuliffe E, O’Donovan D. Unchallenged good intentions: A qualitative study of the experiences of medical students on international health electives to developing countries. Hum Resource Health 2014;12(1):49. https://doi.org/10.1186/1478-4491-12-49 3. Gulsin GS, Johnston PW. Funding your elective. Student BMJ. http://student.bmj.com/student/view-article. html?id=sbmj.d5851 (accessed 4 October 2017). 4. Jeffrey J, Dumont RA, Kim GY, Kuo T. Effects of international health electives on medical student learning and career choice: Results of a systematic literature review. Fam Med 2011;43(1):21-28. 5. Dolea C, Stormont L, Braichet J-M. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ 2010;88(5):379-385. https://doi.org/10.2471/BLT.09.070607 6. Thompson MJ, Huntington MK, Hunt D, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and residents: A literature review. Acad Med 2003;78(3):342-347. https://doi.org/10.1097/00001888-200303000-00023 7. Elit L, Hunt M, Redwood-Campbell L, Ranford J, Adelson N, Schwartz L. Ethical issues encountered by medical students during international health electives. Med Educ 2011;45(7):704-711. https://doi.org/10.1111/j.13652923.2011.03936.x 8. Petrosoniak A, McCarthy A, Varpio L. International health electives: Thematic results of student and professional interviews. Med Educ 2010;44(7):683-689. https://doi.org/10.1111/j.1365-2923.2010.03688.x

Accepted 9 May 2017. Afr J Health Professions Educ 2017;9(4):162-163. DOI:10.7196/AJHPE.2017.v9i4.883

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Short Research Report

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

Selfies 2015: Peer teaching in medical sciences through video clips – a case study J D Pillay, PhD Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, South Africa Corresponding author: J D Pillay (pillayjd@dut.ac.za)

Background. Anecdotally, 2015 was declared the year of the selfie. The theme of selfies is used as an opportunity to engage neuroanatomy students by drawing from it as a newly created art form by means of models and video clips. Objectives. To provide a synopsis of student perceptions of a team project to inform further project development and refinement. Methods. Topics were allocated to teams of 5 - 6 students, constituting a class of 27. Teams were required to prepare a model that would demonstrate a topic, which would be used to produce a video clip presented as a teaching tool. Three focus groups comprising 6 - 8 students subsequently held discussions to determine student perspectives of the project. Results. Students viewed the project as a means of facilitating teamwork and peer learning and of enhancing presentation skills. While all the teams enjoyed the project and found it to be beneficial, students preferred making the model rather than producing the video clip. Nonetheless, students felt particularly accomplished on seeing the completed video clip. A dominant view was that the project provided enhancement of the subject content, pertaining largely to the team’s project, while the knowledge gained of other topics was limited. Some students preferred conventional teaching and found the synopsis provided by the lecturer at the end of each presentation to be particularly useful. Conclusion. This case study provides evidence to support simple strategies of integrating discipline-specific content (‘hard skills’) with general education (‘soft skills’), as required of higher education. Afr J Health Professions Educ 2017;9(4):164-167. DOI:10.7196/AJHPE.2017.v9i4.803

Teaching and assessment strategies require constant personal reflection as to whether these approaches adequately prepare students to meet the discipline-specific knowledge base of the profession (‘hard skills’), while simultaneously developing behavioural and attitudinal skills that empower them to become more socially aware and responsible citizens (‘soft skills’).[1] Integrating soft skills with hard skills is a conceptual principle that higher education promotes and requires, more recently popularised as ‘graduate attributes’.[2] Adapting teaching and assessment practices towards addressing this need from a basic medical science and clinically applied perspective, creates the opportunity and platform to be innovative in identifying new strategies and expanding on conventional practices. Consequently, team learning has become popular in many medical training institutions. In anatomy, the limited dissection potential of the cadaveric brain, and the complexity of the three-dimensional stuctures within it, further creates a substrate for innovative learning. This case study highlights the effectiveness of a team project that embraces the elements of hard and soft skills, team learning and self-directed learning. Topics provided required the preparation and presentation of models through a video clip as a newly created art form, so as to adopt the contemporary social theme: selfies 2015. As it was an innovative curricular activity, it was considered giving specific attention to and evaluating the project from a student’s perspective. More importantly, the project provided a simple strategy that can be used to integrate hard and soft skills, as has become a requirement of most curricula.

Objectives

A class activity has been used as a strategy to integrate hard and soft skills through the concept of a popular social theme related to the creation of an

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art form, and to evaluate the students’ perception of the project in terms of expanding subject knowledge, personal appeal and enjoyment, and future considerations.

Methods

Each team, comprising 5 - 6 students, was allocated a topic in neuroanatomy and was required to prepare a model to demonstrate a particular aspect. Each of the three topics formed part of the neuroanatomy syllabus, but was not taught through formal lectures and practicals. For these topics, student teams were required to prepare a model relevant to the topic and produce a 15-minute video clip incorporating the model as a class presentation. Typically, each of these topics, as in previous years, would have been taught by the lecturer and, as such, contributed substantively to the subject matter. The topics, however, comprised only three of nine key topics of this section of the course and included: • the ventricles of the brain and the flow and circulation of cerebrospinal fluid • the arterial blood supply and venous drainage of the brain and spinal cord • specialised grey matter within the substance of the cerebrum, with particular reference to location, structure and function. There were no specific guidelines for the model preparation or for the presentation of the video clip. In this way, latitude was allowed among students in terms of innovation and team preferences. Students were, however, referred to the subject guide for a clear set of stipulated outcomes to be achieved for each topic in terms of the content that would need to be covered and the appropriate level of detail required. A specific time frame

Short Research Report for completion of the project was also clarified. The teams were assessed equally on the model and the video clip, and a questioning session was held, where team members were questioned on relevant aspects of the topic. The allocation of marks regarding the model focused on key aspects, such as appearance and functionality, and its relationship to other relevant structures in the brain and spinal cord (where applicable). For the video clip, marks were allocated on the basis of presentation aspects, such as voice projection, clarity, engagement with and reference to the model, and pace and level of ease with which the topic content was highlighted. During the question-and-answer session marks were allocated based on how accurately students responded to questions and how well they could explain their responses, as well as the level of participation of all team members. Students were subsequently invited to a focus group interview to document their opinions of the project. The interviews were conducted independently by an external facilitator to limit the bias of the lecturer requesting feedback from students on a teaching event facilitated by the same lecturer. Furthermore, the interviews had taken place after final course assessments were completed so that students felt comfortable during their participation or non-participation, and in providing honest feedback. As these interviews were voluntary, some students chose not to participate or were unavailable owing to the course having been completed by this time. Nevertheless, the focus group discussions were used as an opportunity to establish some awareness of student perceptions of the project and to help to engage academics in reflective practice using student feedback as a reliable source. The questions used for the focus group discussions were based on the principle of reflective practice, which pivots on the ability and need to reflect on what, why and how we do things and to adapt and develop our practice during lifelong learning.[3,4] This has been promoted by and required of higher education teaching. It is usually complemented by regular subject evaluations and subsequent adaptations to teaching and assessment, based on the views of students. As such, basic questions were posed to the focus groups, relating to what students enjoyed about the project, what students did not like about the project and, more importantly, how the project could be enhanced if used for future teaching, learning and assessment. Consequently, the conceptual framework of the study reporting was based on the questions used for the focus group discussions and key themes that emerged from the interviews. Focus group discussions were audio recorded and transcribed by an independent transcriptionist. Thematic analyses were used to analyse the transcripts using the NVivo Qualitative Data Analysis Software, version 10.[5] Themes and sub-themes were created, based in part on the guided questions and data from the transcripts.

Ethical approval

Permission to obtain student feedback was obtained from the Research Ethics Committee, Durban University of Technology (ref. no. 122/15).

Results

Three focus group interviews comprising 21 of a class of 27 students (78% response rate), revealed the following key themes:

The project

A dominant view was that the project integrated theory and practical aspects of the topic, which was found to be enjoyable. Students appreciated working as a team, learning from each other and sharing knowledge. A further view that was often highlighted was the technical challenges faced

in making the video clip. Consequently, many students preferred making the model rather than producing the video clip. There was general agreement that, despite the challenges faced during the process of completing this project, the end product and the experience gained from the endeavour were well worth the effort. Perceptions of reasons for engagement in the project Students viewed the project as a means of facilitating and ensuring teamwork and peer learning and as a vehicle for the enhancement of presentation skills: ‘We learn it practically instead of theoretically.’ ‘Video method was entertaining and increased our concentration; it helped us to learn how to make a video that we can use one day when we qualify.’ ‘We understand better when other students teach us rather than only learning from the lecturer.’ Enjoyment of the project While all the teams enjoyed the project, few took pleasure in making the video. It was noted that the more enjoyable part of the project was related to making the model: ‘Making the model was nice and enjoyable. The video only tested our skills on how to video it. We found making the video stressful.’ Nonetheless, students found the project to be an enjoyable experience, particularly on seeing and presenting the end product (i.e. the video clip): ‘We had a lovely group and we all worked well together and enjoyed working in the group. Seeing our work in the end gave us great satisfaction.’ Less enjoyable aspects of the project Students experienced challenges in making the video and therefore found this to be a less gratifying experience than making the model. Some teams also encountered problems getting the entire group together for the video clip and experienced some technical challenges: ‘We struggled with making the video, we had problems with the sound – it was “hazy”. We also had problems, while presenting, with the timing (delayed) so information did not correspond with what was presented. Getting all the team members together in the limited time available was a problem, so this delayed the making of the video.’

Subject content

Collective enhancement of knowledge and its application There was general consensus that the project provided good enhancement of the subject matter, but that this pertained largely to a particular team’s project, while knowledge obtained of other topics of the section relied on the presentations and a brief synopsis by the lecturer: ‘We covered the content extensively. However, the areas covered by the other teams – we had limited knowledge of these in the short presentation.’ Despite this limitation, students agreed that the exercise was fruitful in enhancing the anatomy learning experience: ‘Making it, seeing the video and presenting it helps to remember better. Anatomy is good when looking at pictures – you better understand it and this helps to remember it better. Doing it yourself enhances memory because you correct it over and over again.’

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Short Research Report The project as an alternative to conventional teaching While most students indicated that the experience was exciting and beneficial, some still preferred conventional teaching and found the lecturer’s synopsis at the end of each presentation very useful: ‘Yes, it was better, as the way it was explained was not the standard form – the video was attention grasping and fun with humour, despite challenges.’ ‘The lecturer provided important information after the presentation. Those areas that we did not do were difficult to understand through the video clip alone, but the lecturer explained it to us after the presentation and this was beneficial.’ Some students were of the view that the experience was not beneficial: ‘The making of the model and the video was a like a repetition and you stop paying attention.’ ‘The entire process of making the model and video – we were not learning but we were stressing about what we are presenting rather than what we are supposed to know.’ There were some students who did not consider the project to be a better alternative to conventional teaching, but indicated that ‘it can be improved on’.

Future recommendations

Suggested areas for improvement of this learning experience A dominant view that emerged from the discussions was that although this method of learning was beneficial, enhancement was needed in the form of technical assistance, especially for making the video: ‘Technical assistance (a tutor) on video making must be made available to us. Also to make some kind of software available in the computer lab. This will help, as making the video can be done on the campus by all rather than at somebody’s house, for example.’ Some students felt that the video clip could be replaced altogether or supplemented by a conventional power-point presentation. Students proposed that a more formative approach to the assessment should be used so that work in progress could be reviewed, with recommendations for improvement. There were also suggestions that more detailed assessment criteria should be outlined. Some indicated that before the allocation of team projects, the lecturer should, as an example, do a similar project with the entire class, which includes dissection of an area, development of a video clip and the presentation thereof.

Discussion

In the past, most medical training institutions taught students by means of curricula that were based on the traditional model of teaching, primarily relying on the transfer of information from teacher to student.[6] Conse quently, students relied on memorisation and largely focused on shortterm recall.[6] The transformation in higher education towards supporting more active student engagement, complemented by the changing needs and interests of students, has warranted more interactive and self-directed learning. Furthermore, there is a growing emphasis on the nature of competencies with which students leave university, which go beyond disciplinary expertise or technical knowledge, to producing generic skills, such as the ability to communicate effectively, work as a team and demonstrate responsibility.[7,8] In this regard, the term ‘graduate attributes’ appears to have achieved fairly widespread acceptance in the most recent literature and is commonly used in the South African context.[9]

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The focus of this study has been on transforming a conventional teaching and assessment tool (i.e. project/assignment) into an endeavour that integrates hard skills, in a self-directed and interactive manner, with soft skills, which contribute towards attaining generic capabilities emphasised in most institutional mandates emanating from the National Plan in Higher Education, 2001.[10] More so, an attempt to incorporate the application of ‘graduate attributes’ in an otherwise content-based task, is inherent in this endeavour. The use of a theme relevant to current social interest provides a stimulating and contemporary appoach. In summary, the following benefits were identified: • The idea of the project was exciting and enjoyable. • The project promoted and enhanced working together as a team. • Most of the learning took place in a self-directed manner and pivoted on peer teaching and learning. • Active engagement in the project and with the subject content promoted a deeper understanding of and more confidence in knowledge of the topic. • The project required expansion in technical skills and abilities. • Great satisfaction/accomplishment was felt upon completion of the project and presentation to the class. The following key aspects were not enjoyed: • There were technical challenges, resulting in difficulties and disappointments in terms of envisaged plans. • The notion of a presentation and questioning session in an auditorium setting was daunting and created anxiety. • There was limited time to work on the project as a team, which became complicated with regard to co-ordinating team meetings outside of formal contact time. • While a high level of mastery was obtained in the topic presented by a team, there were knowledge gaps in the other two topics presented by other groups. Relying on the video clip might not have been adequate. Suggested improvements: • The primary recommendation was that an experienced person who could provide technical assistance for the project was needed. • Formative feedback by a tutor or lecturer would assist in directing students during the process of the project development. • An environment more conducive to video recording would limit the need for teams to co-ordinate meeting outside the university campus. • More clarity on the specifics of mark allocation would provide better direction and focus. While pertinent suggestions were made for future development of the project, the task was recognised as offering an engaging, constructive and exciting space for learning beyond the limits of content-specific theory and practicals.

Study limitations

As each topic covered by the project was not covered during formal lectures, it was not possible to provide information on pre- and postintervention knowledge. For future studies it might be useful to compare student assessment performance (e.g. in a test or examination) on aspects related to these topics with other topics covered by conventional teaching within the same, if not similar, section. Nonetheless, an opportunity for reflection on student experience and insight informs future practice.

Short Research Report Conclusion

Allied health and medical students require active learning engagement that will allow them to move beyond the primary concern of ‘content presentation and assessment’ towards revisiting and improving ways of thinking and connecting information.[11,12] The content developed in this study is recognised as being relevant, as the project involved the development of skills and processes appropriate for life beyond the context of medical science. Acknowledgements. The author wishes to thank Miss Sara Cassim Motala for her valued input and assistance in conducting the qualitative component of the study. Author contributions. JDP was responsible for conceptualising, conducting and reporting the study. Funding. The study was made possible through personal research funds of the author. Conflicts of interest. None.

1. South African Qualifications Authority. SAQA Bulletin 1997;1(1). 2. Andrews J, Higson H. Graduate employability, ‘soft skills’ versus ‘hard’ business knowledge: A European study. High Educ Europe 2008;33(4):411-422. https://doi.org/10.1080/03797720802522627 3. Moon J. Guide for Busy Academics No. 4: Learning Through Reflection. 2005. https://nursing-midwifery.tcd. ie/assets/director-staff-edu-dev/pdf/Guide-for-Busy-Academics-No1-4-HEA.pdf (accessed 18 September 2017). 4. Munby H, Russell T. Educating the reflective teacher: An essay review of two books by Donald Schon. J Curriculum Stud 1989;21(1):71-80. https://doi.org/10.1080/0022027890210106 5. NVivo Qualitative Data Analysis Software. QSR International Pty Ltd, version 10, 2012. http://www.qsrinternational. com/products_nvivo.aspx (accessed 18 September 2017). 6. Lachman N, Pawlina W. Integrating professionalism in early medical education: The theory and application of reflective practice in the anatomy curriculum. Clin Anat 2006;19(5):456-460. https://doi.org/10.1002/ca.20344 7. Barrie SC. A conceptual framework for the teaching and learning of generic graduate attributes. Stud High Educ 2007;32(4):439-458. https://doi.org/10.1080/03075070701476100 8. Kember D, Leung D. The influence of active learning experiences on the development of graduate capabilities. Stud High Educ 2005;30(2):155-170. https://doi.org/10.1080/03075070500043127 9. Griessel H, Parker B. Graduate Attributes: A Baseline Study on South African Graduates from the Perspective of Employers. Pretoria: Higher Education South Africa (HESA) and the South African Qualifications Authority (SAQA), 2009. 10. Department of Education. National Plan for Higher Education in South Africa. Pretoria: DoE, 2001. 11. Gibbs G, Coffey M. The impact of training of university educators on their teaching skills, their apporach to teaching and the approach to learning of their learners. Active Learn High Educ 2004;5(1):87-100. https://doi. org/10.1177/1469787404040463 12. Van Amburgh JA, Devlin JW, Kirwin JL, Qualters DM. A tool for measuring active learning in the classroom. Am J Pharm Educ 2007;71(5):85-97. https://doi.org/10.5688/aj710585

Accepted 30 March 2017.

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Short Research Report

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

The use of low-cost simulation in a resource-constrained teaching environment M Mwandri,1 MD, MMed (Surgery); M Walsh,1 BSc, MBBS, MS, FRCS (Gen); J Frantz,2 BSc, MSc, PhD; R Delport,3 MSc, MEd, PhD 1

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

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

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

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

Background. To improve the management of chest trauma at the University of Botswana, Gaborone, Botswana, we incorporated simulation into a theorybased chest trauma module by developing procedural guides, checklists and low-cost simulation. Objectives. To assess the suitability of low-cost simulation-based training and its impact on students’ proficiency, as well as its general acceptability. Methods. A total of 39 medical students who completed their surgical rotation and 20 intern doctors in their first clinical rotation participated. A checklist was used in a pre- and post-test design to assess procedural proficiency, and a rating system categorised scores. Thirteen content-based items assessed the students’ knowledge relating to the diagnosis and management of a chest injury and one item assessed their ability to perform the procedure correctly. A questionnaire was administered after the second assessment to evaluate the acceptability of the training module. Findings were summarised by median, proportion and range, and pre- and post-test outcomes were compared by Student’s paired t-test. Results. Pre- and post-test assessment scores differed significantly (median (range) 11.3 (4.5 - 21.0) and 19.5 (15.5 - 23.0), respectively (p<0.001)). The proportions of participants’ scores categorised as ‘full proficiency’ rose from 7% to 42%, and ‘reasonable proficiency’ from 30% to 60%, while both ‘some proficiency’ and ‘poor proficiency’ decreased from 50% and 20% to 0%. Most (93%) participants ‘strongly agreed’ that the training module was acceptable. Conclusion. Our results demonstrate the suitability of low-cost simulation for training and assessment in resource-constrained settings. Afr J Health Professions Educ 2017;9(4):168-170. DOI:10.7196/AJHPE.2017.v9i4.829

Chest trauma is one of the most common surgical conditions seen in our teaching hospital at the University of Botswana and in the southern African region.[1] Therefore, intercostal chest drain (ICD) insertion is regarded as a core skill in the medical curriculum. During surgical rotations and assessments we observed varying exposure of students to surgical conditions, despite the high surgical disease burden, and also varying levels of competence in managing chest injuries. Simulation-based training plays a significant role in current surgical training practice,[2] and we hypothesised that chest trauma management, knowledge and skills may be improved by employing low-cost task trainers. Simulation describes a full-range use of physical objects (task trainers) or situations for mimicking real-life scenarios or functions during training. It plays a significant role in current health professions education, and was introduced to address the decreasing exposure to real patients in surgery[2,3] and improve teaching and assessment in medicine.[4] Simulation-based training and its assessment for both cognitive and psychomotor learning domains have been studied extensively.[5] This study employs a pre- and post-test design[6] to assess an educational intervention based on the Kirkpatrick evaluation model for training.[7] The Kirkpatrick model defines four evaluation levels. Levels 1 and 2 evaluate short-term outcomes, such as acceptability and change in level of knowledge and skills, while levels 3 and 4 evaluate behavioural change associated with training and the organisation’s ultimate gain. We hypothesised that chest trauma management, knowledge and skills may be improved by employing simulation in the form of locally made lowcost task trainers. The overall purpose of this pilot study was to improve management of chest trauma. We included simulation in the previously

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theory-based chest trauma training module and thereafter tested trainees’ knowledge and skills with regard to the effectiveness of the intervention. We also tested acceptance of this new simulation-based module.

Methods

Research setting

The study was conducted at the University of Botswana’s new Faculty of Medicine, where the competence-based curriculum employs a problembased learning approach and traditional patient encounters.

Research design

This study employed a quantitative pre- and post-test design.

Population and sampling

All medical students (n=41) were invited to take part in the study after their last surgical rotation and newer intern doctors (n=20) during their initial rotation – before being deployed to the surgical rotation. Using convenience sampling we included 35 medical students and 14 interns. There were 39 partici pants in the pre-test assessment and training; 14 completed all three sessions, i.e. the pre-test assessment, training and post-test assessment.

Data collection instrument

A checklist developed for the module was used for the pre-test and post-test assessments. Thirteen content-based items (total score of 22) evaluated the students’ knowledge relating to the diagnosis and management of a chest injury (cognitive domain) and one item (total score of 3) evaluated their ability to perform the procedure correctly (psychomotor domain). A rating

Short Research Report scale was developed to describe their performance scores, and a survey based on Kirkpatrick’s model was used to assess the trainees’ acceptability of the module by trainees.

Data collection and procedure

Management of chest trauma was assessed before and after a training intervention. The training module comprised theoretical and practical sections. The theoretical component covered the clinical presentation, chest radiograph interpretation and management of chest trauma. The practical component was taught in a simulated environment using task trainers as low-cost simulation for the insertion of ICDs. The task trainers were built from affordable material and comprised a suture trainer and ICD-insertion trainer, respectively (Fig. 1A and B). Knowledge and understanding (cognitive assessment) and procedural proficiency (psychomotor ability) were evaluated using a checklist that was developed in accordance with the Advanced Trauma Life Support programme founded by the American College of Surgeons. The assessment was designed to evaluate suitability and acceptability of the proposed module – not for summative assessment purposes. The checklist evaluated students’ knowledge and understanding of indications for chest drain insertion, which included the use of diagnostic criteria for chest radiograph interpretations, anatomical considerations in ICD insertion, indications for referral for surgery, maintenance of ICD patency and monitoring for abnormalities regarding drainage. There were multiple possibly correct responses for each item and a mark of 0.5 was allocated for each correct response. The psychomotor section of the checklist assessed appropriate handling of instruments, economy of movements during a procedure, correct forming of knots, and correct suturing. A mark of 0.5 was awarded for each correctly performed step. If students demonstrated smooth forward progression of the procedure (incision and insertion of the drain, suturing to control leakage, anchoring of the drain), they were awarded 1 mark, as it closely demonstrates mastering of psychomotor skills and not merely observing how to perform a task. The pre-test assessment and training were performed on the same day. The post-test assessment employed the same checklist as the pre-test and

was conducted 2 weeks after the training session. The scores obtained from the assessments were converted to percentages and a rating system was designed to categorise scores, ranging from ‘poor proficiency’, ‘some proficiency’, ‘reasonable proficiency’ and ‘full proficiency’ for percentage scores of <40, 40 - 59, 60 - 79, and 80 - 100, respectively. After the training session, a course evaluation survey employed Likert scales to assess acceptance of the model as formal training for chest trauma, clarity of the content, and relevance of the content to practise, as perceived by participants who completed pre- and post-training assessments.[8]

Data analysis

Collated information was analysed using SPSS 16 (SPSS Inc, USA). Mean, median, frequency and proportion were summarised to describe the preand post-training test assessment scores. Student’s paired t-test was used to compare pre- and post-test performance. A p˂0.05 value indicated a statistically significant change. Scores were graded using the described rating system.

Ethical approval

Ethical approval for this study was granted by the University of Botswana (ref. no. X-REF:UBR/ETHI/21). Written informed consent was obtained from each of the participants.

Results

Thirty-nine participants took the pre-test and underwent training. Fourteen (36%) participants completed all planned sessions, completing the pre-test, training and post-test assessments. The analysis comparing the pre- and post-training tests was performed on the 14 participants who completed all the planned sessions. The median (range) scores for pre- and posttest assessments were 11.3 (4.5 - 21.0) and 19.5 (15.5 - 23.0), respectively (p<0.001). The median scores for the psychomotor assessment (chest drain insertion skill) improved from 1.0 (0 - 3.0) to 2.5 (1.5 - 3.0) of a possible score of 3 in the pre-test and post-test assessments, respectively. Six (42%) participants attained ‘full proficiency’ grades in the post-test assessment compared with 1 (7%) in the pre-test. Participants in the ‘reasonable

Fig. 1. (A) Step-wise illustration of creating a suture trainer. (B) Intercostal chest drain-insertion trainer.

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Short Research Report proficiency’ grade rose from 4 (30%) to 8 (60%) in pre-test and post-test assessments, respectively. Participants in the ‘some proficiency’ and ‘poor proficiency’ grades in the pre-test decreased from 6 (50%) and 3 (20%), respectively, to 0% in the post-test. The majority of participants (93%) strongly agreed that they would accept this module as their formal training for chest trauma.

Discussion

This study evaluated the usefulness and acceptability of low-cost simulation in a resource-limited environment. The process undertaken represents the initial two levels of the Kirkpatrick model: change of knowledge following the training and reaction from the trainees.[7,8] Several previous studies have demonstrated the effectiveness of simulation in assessment.[2-4] At our university and other universities in developing countries, medical training has not fully exploited the use of simulation for training and assessment.[3] Despite the demonstrated advantages of simulation in surgical training, the literature on this topic in sub-Saharan Africa is scarce – probably because of the limited use of simulation.[2,3] Among the possible reasons for these low usages are: high cost of purchasing simulation models and lack of logistical and organisational initiatives.[2,3] Although there is an abundance of patient encounters for trainees and a high disease burden in many developing countries, simulation may still form an important part of training and assessment of critical skills. In comparable situations, simulations have been used for the initial training of novices, e.g. in the military and aviation industries.[2,4]

Study limitations

The main limitations of this study were: (i) loss to follow-up of participants in the post-test assessment, which may affect the generalisability of our findings; and (ii) ethical issues that restricted the use of control groups in this pilot study, leading to the use of single-group pre- and post-test designs, which are known to have variations in estimations of the effect size of outcomes.

Conclusion

The results of this study indicated that low-cost simulation can be a useful and readily available aid for training and assessment in a resource-

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constrained environment. If used in conjunction with the existing surgical curriculum, low-cost simulation appears to contribute to the knowledge and skills of our students and trainees. Low-cost task trainers, as described in this study, are an effective option for training and assessment. We would recommend an extension of this type of model to the rest of the curriculum. We also recommend that further studies should be done to evaluate the long-term impact of low-cost simulation on trainees’ behavioural change and patients’ outcome.

Acknowledgements. We acknowledge the contributions of Drs S Kuskov, M Kwati and K Mmalane from Princes Marina Hospital, Gaborone, Botswana, and the 2014 Sub-Saharan Africa-FAIMER Regional Institute (SAFRI) faculty and fellows for their support and contributions. Author contributions. MM: conception, design, analysis, data interpretation and writing of the manuscript; RD: conception, design, data interpretation and critical revision of intellectual content; JF: conception, design, data interpretation and critical revision of intellectual content; and MW: data interpretation and critical revision of intellectual content. All the above-named authors approved publication of this manuscript. Funding. None. Conflicts of interest. None.

1. Clarke DL, Quazi MA, Reddy K, et al. Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg 2011;142(3):563-568. https://doi.org/10.1016/j. jtcvs.2011.03.034 2. Raison N, Ahmed K, Dasgupta P. Role of simulation in surgical training. Eur Urol Focus 2016;2(1):63-64. https:// doi.org/10.1038/nrurol.2016.147 3. Taché S, Mbembati N, Marshall N, et al. Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania. Hum Resour Health 2009;7:64. https://doi.org/10.1186/14784491-7-64 4. Scalese RJ, Obeso VT, Issenberg SB. Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med 2008;23(1):46-49. https://doi.org/10.1007/s11606-007-0283-4 5. Kardong-Edgren S, Adamson KA, Fitzgerald C. A review of currently published evaluation instruments for human patient simulation. Clin Simul Nurs 2010;6(1):e25-e35. https://doi.org/10.1016/j.ecns.2009.08.004 6. Maier-Riehle B, Zwingmann C. Effect strength variation in the single group pre-post study design: A critical review. Die Rehabilitation 2000;39(4):189-199. https://doi.org/10.1055/s-2000-12042 7. Kirkpatrick D, Kirkpatrick J. Evaluating Training Programs: The Four Levels. 3rd ed. California: Berrett-Koehler, 2006. 8. Allen IE, Seaman CA. Likert scales and data analyses. Qual Progress 2007;40(7):64-65.

Accepted 15 June 2017.

Research

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

Implementing the Angoff method of standard setting using postgraduate students: Practical and affordable in resource-limited settings A G Mubuuke, BSc, MSc, MPhil, PhD Fellow; C Mwesigwa, BDS, MSc; S Kiguli, MB ChB, MMed, MHPE College of Health Sciences, Makerere University, Kampala, Uganda Corresponding author: A G Mubuuke (gmubuuke@gmail.com)

Background. Cut scores for students’ assessments have always been arbitrarily determined in many institutions. Some institutions have adopted reliable methods of determining cut scores, such as the Angoff method. However, use of this method requires many experts, making it difficult to implement in resource-limited settings. The possibility of involving postgraduate students in implementing the Angoff method of setting cut scores could be the solution to this problem. Objectives. To explore the knowledge and practices of faculty regarding standard setting and the feasibility of using postgraduate students when implementing the Angoff method. Methods. This was an exploratory operations research study in which data were collected during focus group discussions. Students were trained to use the Angoff method, i.e. a previous examination, in which the pass mark was 50%, was used to evaluate the method. Results. Initial findings showed that faculty in the consortia of schools did not know what standard setting and the Angoff method entailed and had never used this approach. The postgraduate students involved in implementing the Angoff method of setting cut scores were excited and interested in engaging in the exercise; the pass mark they arrived at was 61.21%. Conclusion. The study demonstrated that it is feasible to use the Angoff method of determining pass marks, even in resource-limited settings. This can be made possible by involving postgraduate students in the absence of enough faculty experts. Afr J Health Professions Educ 2017;9(4):171-175. DOI:10.7196/AJHPE.2017.v9i4.631

During curriculum development, teachers adopt various criteria to assess the students’ level of competence. These are put in practice during tests and examinations. Ideally, examiners need an educational method to determine cut scores to distinguish non-competent from competent students. The practice of determining cut scores is called standard setting.[1,2] A cut score is a point on a scale that separates one performance standard from another. The traditional arbitrary methods used to define cut scores, such as responding correctly to 50% of the test items, cannot provide robust and valid evidence to judge student performance. Therefore, the use of these methods may be difficult to justify. Consequently, there is a need to set cut scores using methods that are robust, valid, and provide a fair judgement of student performance. Although no method has been identified as the benchmark for setting cut scores, the use of scientific methods with a systematic approach provides a balanced judgement of student performance.[3-5] There are two broad categories of standard setting: (i) the criterion or absolute method, where setting a cut score is independent of test results;[6-9] and (ii) the norm-referenced or relative method, where cut scores are set depending on test results.[6-9] Norm-referenced methods are generally used to rank students, while criterion-referenced methods are used to judge student performance against a set benchmark.[7-9] The criterion-referenced methods for setting cut scores in health professions education usually involve a number of subject experts making judgements about test items and proposing a final cut score; this is labour intensive, costly and subjective. The current study focused on a feasible way of using the Angoff method of setting cut scores in resource-limited settings with few experts. The original Angoff and modified Angoff methods have been widely used in setting cut scores.[8] The original method requires a panel of subject

experts to determine the probability of a minimally competent student answering a test item correctly. It requires each expert to estimate the probability of each test question. The final cut score becomes the average of the sums of different probabilities from all experts.[10] In the original Angoff method, experts determine the probabilities, i.e. they can select any probability ranging from 0 to 1 (0.90, 0.44, 0.56, etc.). The modified Angoff method restricts the probabilities to eight choices (0.2, 0.4, 0.5, 0.6, 0.75, 0.90, 0.95, ‘do not know’).[7, 11] The Angoff method of setting cut scores is resource intensive and requires many well-qualified experts in the test domain. In many institutions, there are not enough qualified experts to form a reliable panel in any one particular field. The few available have to divide their time between many tasks other than student assessment.[12,13] One needs to find a way of effectively using the available resources to implement the Angoff method in a resource-limited context. This study had two purposes: (i) to explore the knowledge and practices of faculty about standard setting and the use of the Angoff method; and (ii) to explore the feasibility of using postgraduate students as panel members when implementing the Angoff method of standard setting.

Methods

Study setting

The study took place in Uganda and involved faculty from five medical schools: Makerere University College of Health Sciences (MaKCHS), Kampala; Mbarara University of Science and Technology; Gulu University; Busitema University; and Kampala International University. Under the auspices of the Medical Education Partnership Initiative (MEPI), the five Ugandan medical schools formed a consortium – the Medical Education for

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Research Equitable Services for All Ugandans (MESAU) – to have one unified voice aimed at improving the training of health professionals in the country. This consortium developed common competencies and suggested the adoption of common assessment practices.

Study design

This was a hands-on research study in which knowledge and practices of lecturers regarding standard setting and the Angoff method were initially explored across the MESAU schools during focus group discussions. After conducting a baseline exploration of lecturers’ knowledge and practices of standard setting, we investigated the feasibility of using postgraduate students as part of the panel of experts to set cut scores for undergraduate students, employing the original Angoff method. This was done as a pilot study in the radiology department of one of the MESAU schools. Six postgraduate students in this department and two faculty members were recruited through convenience sampling to participate in the scoring of examination questions. Before the scoring exercise, three short training sessions, one per day, were organised for the relevant students and faculty. Each training session lasted ~25 minutes and focused on the meaning of standard, advantages and using the original Angoff method to set cut scores. Scheduling of the training sessions into three short sessions allowed the postgraduate students time for other learning activities. In the last session, the 6 postgraduate students and 2 faculty members were briefed about the exercise and possible issues were clarified. The following day, the relevant postgraduate students and faculty members were invited to form a panel of experts (also referred to as judges), who would score the test questions and provide a final pass mark. A previously written test for undergraduate students was used for the exercise. This test had 30 questions; a student had to circle one single-best correct option. To avoid bias, the correct answer was not shown to the judges. The key guiding question for the panel during the exercise was: What is the percentage chance of a borderline student answering this question correctly? The researchers carefully formulated the question using simple language. They avoided educational terminologies because the intended audience comprised non-educational experts. Therefore, the researchers further defined a borderline student as one who spends a minimum of time studying, is good enough to pass the examination and often finds it difficult to score above the pass mark. Each judge was then requested to note down any percentage chance for each test question for all 30 questions. After the initial round of scoring, the judges discussed the scores among themselves. The facilitator also afforded each group the opportunity to express their opinions. Subsequently, a second round of scoring was done, the various average scores from the 8 judges were compiled, and a final cut score for the test was determined. After setting the cut score for the test, the 6 postgraduate students who participated in the exercise were invited to participate in a 30-minute focus group discussion the following day to share their experiences. One key assumption was that a postgraduate student in radiology had the required competency to determine whether a borderline undergraduate medical student can answer a given radiology question correctly.

Data collection and analysis

Focus group discussion was the primary method of collecting data in each MESAU school. Two focus group discussions, which included the lecturers, were conducted in each school, giving a total of 10 focus group discussions conducted across the 5 MESAU schools. Each focus group comprised 6 participants. The researchers audio recorded and later transcribed the

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responses from these discussions. Two of the researchers then read through the data. Thematic analysis was used,[14] and the researchers analysed the data manually. During this process, raw data were read, and through a series of iterative and inductive open and axial coding, codes and themes were developed manually.[15]

Quality assurance

The researchers stored the data electronically and secured these with a password. Participants were invited to validate the emerging themes to ensure credibility of the data. Additionally, researcher bias was minimised by the researchers, avoiding all preconceived ideas or experiences on the subject being investigated and practising reflexivity and bracketing throughout the research process.

Ethical considerations

Participants provided written informed consent. They were not identified by name and their responses were kept anonymous and confidential. Permission to conduct this study was granted by the Research and Ethics Committee, School of Health Sciences, MaKCHS (ref. no. 2014-045).

Results

The lecturers generally had limited knowledge of standard setting and mostly did not practise it. One major theme arose from the analysis, with key representative responses, as indicated below.

Knowledge and practices of lecturers regarding standard setting The lecturers who participated in the focus group discussions lacked knowledge of standard setting in assessment, almost all of them agreeing that they did not know what it means. A few had heard about the concept, but did not know what it entailed. Some typical responses are given below: ‘I have not heard about standard setting and cannot tell what it exactly means.’ ‘I have heard about standard setting from a few seminars and workshops I have attended – that it involves setting pass marks. However, I feel am not competent enough to explain what it is.’ ‘I am not an education expert and therefore I cannot commit myself to offer an explanation as to what standard setting means.’ From the responses listed above and many more that echoed a similar interpretation, it is clear that lecturers involved in student assessment lacked knowledge of standard setting. Moreover, the lecturers had never practised standard setting in their institutions during assessment: ‘Why should I practise what I do not know?’ ‘We cannot practise standard setting unless someone teaches us what it is and how it should be done.’ ‘Although I have a little knowledge about standard setting, I have never practised it myself.’ From the responses it was therefore clear that the faculty members who participated did not know what standard setting is, and had never practised it. Additionally, none of the lecturers had ever heard about the Angoff method of setting a cut score: ‘We have never heard about that terminology and do not know what it means.’ Using postgraduate students, it was observed that the final cut score determined from the scoring was 61.21%. Table 1 illustrates how each test question was scored by each judge, the various averages of the raters, as

Research Table 1. Scores (%) from each judge and final cut-score Judge and score, % Question

Cut score, mean (SD)

54.75 (4.71)

58.12 (2.23)

54.00 (3.82)

54.75 (4.17)

54.00 (5.29)

54.12 (4.22)

55.00 (4.63)

56.88 (2.64)

58.75 (7.44)

55.13 (3.56)

63.13 (4.58)

50.25 (1.28)

60.38 (3.34)

59.63 (5.78)

80.63 (4.96)

71.63 (6.58)

61.50 (4.87)

81.63 (4.75)

100

87.88 (7.00)

51.88 (2.90)

57.88 (4.52)

67.13 (4.52)

54.75 (3.96)

63.50 (6.05)

80.38 (3.34)

53.00 (3.55)

60.25 (3.15)

65.63 (5.63)

58.50 (5.18)

51.38 (4.31)

60.40

61.80

61.27

61.33

60.53

61.21 (9.88)

Final average cut score for minimum competency 62.40

60.77

61.20

SD = standard deviation.

well as the standard deviations (SDs) from the mean scores. From the SDs, it can be observed that across the test items, there was generally no large dispersion of scores from the mean. Also, the final cut score fell within the mean cut score of each judge for the 30 questions. The entire exercise of setting the cut score lasted 90 minutes. Having participated in the exercise, a focus group discussion was conducted with the postgraduate students to explore their experiences. The findings are presented below.

Experiences of postgraduate students after the scoring exercise

The focus group discussion conducted with postgraduate students after the standard-setting exercise revealed interesting and encouraging experiences. All postgraduate students who participated expressed excitement about becoming involved, as can be observed in the following responses:

‘ This was a whole new experience to me. It was indeed interesting for me to get involved in determining other students’ pass marks. I wish ours were determined like this before.’ ‘This is the best way to go and I thank our teachers for getting us this opportunity. I feel that this system is fair to students and will be welcomed if implemented fully.’ ‘We enjoyed the whole exercise. This method of determining pass marks where people follow a systematic process is not only fair, but also acceptable. Just saying that the pass mark is 50% does not make sense.’ From such responses, it appears that the graduate students enjoyed the exercise and supported setting a pass mark using the relevant steps.

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Research Although they generally accepted the method, the graduate students expressed some concerns: ‘This is very good. However, I have seen that one needs several lecturers to do it.’ ‘The exercise of setting the pass mark required some time. In my opinion, time considerations need to be put in place before carrying out the exercise, like setting exams early enough and determining the pass mark before students sit for the exam.’ ‘Availability of time is the most crucial thing here. Do lecturers have enough time to carry out this exercise?’ The abovementioned responses single out the factor of time, which should be considered when planning implementation of this exercise. However, the graduate students had a solution to mitigate this: ‘Like we sometimes do participate in teaching of undergraduates, we can also participate in determining a pass mark alongside our lecturers. If this exercise is carried out early enough before exams commence, the time factor can be fairly addressed.’ ‘We can dedicate some time on our timetables to participate in determining a pass mark for our undergraduate fellows. At least, if it is time tabled, there should be no problem. Indeed, reserving a little time to participate also refreshes our memories of what we learned earlier.’ From the responses, it appears that graduate students were eager to participate and allow some time for this exercise.

Discussion

This study explored lecturers’ knowledge and practices of standard setting across MESAU schools and the possibility of using postgraduate students in the standard-setting process.

Knowledge and practices of lecturers regarding standard setting Findings of the current study illustrated that the lecturers lacked adequate knowledge of standard setting, specifically of the Angoff method, which they did not practise before. While this was a significant observation, it may not be surprising. Many lecturers in these medical schools lack formal training in medical education and are not very conversant with issues of standard setting. The majority are recruited into teaching owing to excellent grades in their professional disciplines, which do not involve educational issues. This probably explains the observation that they lacked knowledge about standard setting. Our study also points to a lack of adequate faculty-development programmes in standard setting in these MESAU institutions. Many lecturers in medical schools lack educational knowledge and skills; this is not unique to the MESAU schools, but has been widely reported elsewhere.[7] Many institutions have taken on the initiative to design and implement facultydevelopment programmes, targeting specific faculty needs to improve teaching, learning and assessment.[13]

Feasibility of employing postgraduate students in the standard-setting process The study also explored the feasibility of implementing the original Angoff method using postgraduate students. Findings indicated that they fully participated in and were very excited about the exercise. One would have expected these students to complain about the additional workload alongside

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their usual learning activities. It is, however, not clear why postgraduate students were excited and found the exercise interesting. One can argue that it probably benefited them educationally, as it allowed them to revise and refresh their memories with regard to previous learning material. One can also argue that as their own cut scores were predetermined when they were students, they were eager to participate in the process of determining cut scores for their colleagues. Moreover, it appears as if the standard-setting process provided what could be deemed a credible cut score for the test, despite the participation of postgraduate students as judges. The final cut score for the test used in this study was 61.21%, whereas a cut score of 50% had previously been used for this test. The cut score of 61.21%, as determined by the panel of judges, seems a fair, valid and reliable representation of the difficulty of the test compared with the 50% score. This can be supported by previous records, which show that the lowest-scoring student in this particular test achieved 63%, which is above our cut score of 61.21%, determined by the Angoff method. This vindicates our exercise and suggests that the Angoff method had some degree of reliability and credibility. This observation is in agreement with findings from Verhoeven et al.,[1] who reported that using recent graduates as judges when implementing the Angoff method can be credible and reliable. One could argue that postgraduate students are not subject experts. However, all such students have studied the undergraduate curriculum and should have the minimum competency to offer an opinion regarding the probability of an average undergraduate student answering a question correctly. The advantage of the Angoff method is that judges can initially score the questions and then discuss their scores before continuing with another round of scoring. With the exercise taking place in the presence of two faculty members, the discussion most probably offered valuable insights, which encouraged the participating postgraduate students to reflect on and think carefully about their initial scores and the test items before the second round of scoring. To tap into the advantages of the Angoff method while simultaneously not overburdening the few available academic staff, this study proposes involving postgraduate students in various departments to become part of the panels, together with some faculty members, as a way of implementing the Angoff method in the context of limited human resources. However, the postgraduate students need to be trained alongside faculty so that they know what is expected of them. The issue of time, as observed from the responses, should not be overlooked, as the exercise can appear as an additional workload to the already busy students. It is suggested that faculty need to take into consideration postgraduate students’ time. It was feasible to divide the training into three short sessions of 25 minutes per day for 3 days, instead of a 2-hour session for 1 day. The suggestion from the participating students that examinations be set early and the exercise be time tabled is another way of addressing the time factor. Furthermore, postgraduate students could receive an assessment mark for participating in this exercise as a way of motivating them. Without proper scheduling of time, taking into consideration postgraduate students’ learning periods, their involvement is not likely to succeed. From the literature, it appears that there are no studies exploring the possibility of postgraduate students as judges when setting cut scores, using the original Angoff method, in the event of limited academic staff. Although Verhoeven et al.[1] studied this aspect using recent graduates on progress tests, they employed the modified Angoff method and provided

Research correct answers to the judges before the scoring exercise, an observation that arguably creates bias. By providing the correct answer, the mind of the judge is influenced and a seemingly difficult question might be viewed as easy, and vice versa, which creates some degree of bias. We decided not to provide answers to the judges to avoid such a scenario. Additionally, the modified Angoff method that Verhoeven et al.[1] used also restricts judges to specific scores.[7] The disadvantage is that judges are limited to the use of predetermined scores, which can be viewed as a way of influencing their decision. We left the scoring open, so that the judges could carefully consider the question and provide an appropriate score from a very wide range of possible scores. Therefore, the contribution of this study is worth noting and building on. Our approach of training the judges before the exercise most probably eliminated all uncertainties in the minds of the judges; therefore, it was clear what was expected of them. This eliminated issues of providing correct answers to the judges, which could lead to bias. Nonetheless, findings from our study generally concur with those of Verhoeven et al.[1] and further illustrate that postgraduate students can be judges when using the Angoff method. In our study, short training sessions for the student judges possibly eliminated the requirement of providing correct answers to them when scoring. Simple, short training sessions, e.g. half a day, are specifically encouraged. Because of these observations, we suggest using postgraduate students as part of the panel that determines cut scores for undergraduate students in situations where there are not enough subject experts to form such a panel in a resource-limited setting.

Study limitations

We used postgraduate students in only one department, a major limitation of the study. It is difficult to recommend a major roll-out using data from only one department. We therefore suggest that such an exercise be tried and evaluated in other departments, and incremental implementation be carried out rather than a major roll-out at the MESAU schools and other schools. However, the information gathered provides a foundation on which this exercise can be applied elsewhere and findings compared.

Further research

A major focus of this study was addressing the human resource gap when using the Angoff method; it did not specifically focus on how time can be used optimally when involving postgraduate students. This provides a direction for future research.

Conclusion

Our study has demonstrated that postgraduate students can be efficiently used as a cost-effective measure to address the human resource gap when

employing the Angoff method of setting cut scores. There is also a need for faculty-development programmes in assessment and standard setting, so that faculty can have a basic knowledge of what these programmes entail. In this manner, the advantages of introducing innovations, such as standard setting, are most likely to be reasonably well accepted instead of being completely rejected. Acknowledgements. We acknowledge support from the Medical Education for Equitable Services for All Ugandans-Medical Education Partnership Initiative (MESAU-MEPI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Fogarty International Center or the National Institutes of Health. Author contributions. AGM: conceived the idea, drafted the protocols for ethical reviews, participated in designing the study tools and in data collection and analysis, and wrote the initial draft; CM: refined the idea, participated in designing the study tools and in data collection, and reviewed the initial draft; SK: guided the team during the process and reviewed the final draft. Funding. This study was funded by the MESAU-MEPI Programmatic Award (ref. no. 1R24TW008886) from the Fogarty International Center. Conflicts of interest. None. 1. Verhoeven BH, van der Steeg AFW, Scherpbier AJJA, Muijtjens AMM, Verwijnen GM, van der Vleuten CPM. Reliability and credibility of an Angoff standard setting procedure in progress testing using recent graduates as judges. Med Educ 1999;33(11):832-837. https://doi.org/10.1046/j.1365-2923.1999.00487.x 2. Muijtjens AMM, Schuwirth LWT, Cohen-Schotanus J, Thoben AJNM, van der Vleuten CPM. Benchmarking by cross-institutional comparison of student achievement in a progress test. Med Educ 2008;42(1):82-88. https://doi. org/10.1111/j.1365-2923.2007.02896.x 3. Friedman B-D M. AMEE Guide No. 18: Standard setting in student assessment. Med Teach 2000;22(2):120-130. https://doi.org/10.1080/01421590078526 4. Taylor CA. Development of a modified Cohen method of standard setting. Med Teach 2011;33(12):e678-e682. https://doi.org/10.3109/0142159X.2011.611192 5. McHarg J, Bradley P, Chamberlain S, Ricketts C, Searle J, McLachlan J. Assessment of progress tests. Med Educ 2005;39(2):221-227. https://doi.org/10.1111/j.1365-2929.2004.02060.x 6. Norcini J, Guille R. Combining tests and setting standards. In: Norman GR, van der Vleuten CPM, Newble DI, eds. International Handbook of Research in Medical Education. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2002. 7. Norcini J. Setting standards on educational tests. Med Educ 2003;37(5):464-469. https://doi.org/10.1046/j.13652923.2003.01495.x 8. Bandaranayake RC. Setting and maintaining standards in multiple choice examinations: AMEE Guide No. 37. Med Teach 2008;30(9):836-845. https://doi.org/10.1080/01421590802402247 9. George S, Sayeed Haque M, Oyebode F. Standard setting: Comparison of two methods. BMC Med Educ 2006;6:46. https://doi.org/10.1186/1472-6920-6-46 10. Angoff WH. Scales, norms, and equivalent scores. In: Thorndike RL, ed. Educational Measurement. 2nd ed. Washington, DC: American Council on Education, 1971:508-600. 11. Gagnon R, Charlin B, Coletti M, SauvĂŠ E, van der Vleuten CPM. Assessment in the context of uncertainty: How many members are needed on the panel of reference of a script concordance test? Med Educ 2005;39(3):284-291. https://doi.org/10.1080/10401334.2010.488197 12. Verhoeven BH, Verwijnen GM, Muijtjens AMM, Scherpbier AJJA, van der Vleuten CPM. Panel expertise for an Angoff standard setting procedure in progress testing: Item writers compared to recently graduated students. Med Educ 2002;36(9):860-867. https://doi.org/10.1046/j.1365-2923.2002.01301.x 13. Prince KJAH, Scherpbier AJAA, van Mameren H, Drukker J, van der Vleuten CPM. Do students have sufficient knowledge of clinical anatomy? Med Educ 2005;39(3):326-332. https://doi.org/10.1111/j.1365-2929.2005.02096.x 14. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45. https://doi.org/10.1186/1471-2288-8-45 15. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa

Accepted 13 June 2017.

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

Medical students’ perspectives on the anatomy course at the University of Zimbabwe R Siwela, MSc; G Mawera, DPhil Department of Anatomy, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe Corresponding author: R Siwela (rudosiwela@gmail.com)

Background. Traditional academic-led anatomy teaching methods, such as didactic lectures and cadaver dissections, are on the decline, as more student-led teaching methods are being adopted. Objectives. To assess medical students’ perspectives on the teaching objectives achieved by traditional teaching methods (lectures, cadaver dissections and tutorials) used in the anatomy course. Methods. A cross-sectional survey comprising a matrix questionnaire was performed among selected 1st-year - 5th-year medical students, using stratified random sampling. The students were requested to select a score between 0 and 5 to represent the fit between the learning outcome and the teaching method, with 0 being no fit and 5 representing a perfect fit. Results. Lectures had the highest mean score of 3.871 for the ability to provide medical vocabulary. Cadaver dissection had the highest mean score of 3.488 for its ability to develop team skills. The highest mean score of 3.415 for all three teaching methods combined was recorded for the learning outcome relating to imparting an anatomical foundation, while the lowest mean score of 2.731 was recorded for the development of skills in order to follow complicated instructions. However, no teaching method had an excellent fit (mean ≥4.5) with any of the teaching objectives. Conclusion. The study showed that the three teaching methods being used in the anatomy course were, to a great extent, useful to impart the skills and content base. However, other teaching methods, such as problem-based and team-based learning, have to be considered to achieve the other important learning outcomes. Afr J Health Professions Educ 2017;9(4):176-179. DOI:10.7196/AJHPE.2017.v9i4.822

The teaching of anatomy has been one of the cornerstones of medical education for centuries.[1,2] Knowledge of anatomy assists a physician in examining a patient, determining a diagnosis, and communicating these findings to the patient and other medical professionals.[2] Traditionally, anatomy has been learnt using didactic lectures and practical cadaver dissections.[1,2] Anatomy lectures have been an efficient way of introducing basic concepts and conveying basic knowledge to medical students.[3] Cadaver dissection, on the other hand, has been used to impart an appreciation of 3D anatomy and to familiarise students with the human body.[4] Nonetheless, these methods have been criticised for their inability to convey long-term knowledge, their propensity to overload students with information that may not be necessary for clinical practice, and the associated large expenses for storage, maintenance and disposal of human cadavers.[2,3,5] Therefore, the years spent learning anatomy are seen to be largely labour and resource intensive, but potentially not useful.[2] To counteract the abovementioned pitfalls, the teaching of anatomy has been modified to be less reliant on academic-led teaching, instead emphasising student-led learning, using methods such as problem-based learning (PBL) and team-based learning (TBL).[6] PBL at its most basic level is a teaching method that uses patient problems as a context for students to learn problem-solving skills and acquire knowledge about the basic and clinical sciences.[7] TBL, however, is a small-group learning method during which students are guided to apply conceptual knowledge through activities that involve individual work, teamwork and immediate feedback.[8] The rationale behind these methods has been that they create a more usable body of knowledge and

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that the most important medical skills for treating patients are the solving of problems rather than memorising of information.[4,5] These new student-led methods of teaching and their variations are being increasingly embraced by medical schools in developed countries, as they are in line with educational theory.[1] Despite the adoption of these student-orientated methods, there is still widespread debate on their pedagogical advantages.[2,9] The small-group sessions in PBL have been shown to suffer from poor attendance, variable student preparation and inconsistent group problem-solving achievement.[10] Furthermore, few students come truly prepared to engage in active discourse and too much time is spent on covering basic factual material rather than applied problem solving.[10] In Africa, there are a few studies on the teaching of anatomy and the modes of instruction. A continental survey of anatomy teaching and the changes in the curricula showed that modern methods of teaching anatomy are being used by a substantial number of medical schools in Africa.[11] Eleven of the 19 African departments that responded were using PBL and had converted to this mode of teaching before 2000.[11] In contrast, a review article on anatomy teaching in Africa concluded that ‘socioeconomic and political instability, failure to rapidly overcome the inertia for change by substituting the old curriculum with a more problem-based system and student-based one and redefining the goals of medical education are some of the issues of concern for Africa, and its ability to keep up in the dynamic world of medical education’.[12] In line with current modifications in the teaching and assessing of anatomy in medical schools globally, the Department of Anatomy, University

Research Table 1. Blank matrix questionnaire Teaching methods Dissection by students

Teaching aim

Didactic teaching only

Tutorials

1. To impart an anatomical foundation 2. To provide background for clinical disciplines 3. To provide medical vocabulary 4. To appreciate anatomical variation 5. To relate structure to pathology 6. To provide student-directed learning 7. To develop team skills 8. To develop the ability to think and solve problems 9. To develop skills of following complicated instructions

Table 2. Fitness-for-purpose ratings

Table 3. Demographic data of study participants

Fitness for purpose

Rating

Excellent fit

Mean ≥4.5

Good fit

3.4≤ mean ˂4.5

Moderate fit

2.5≤ mean ˂3.4

Poor fit

Mean ˂2.5

of Zimbabwe needs to make relevant changes to the anatomy course. To improve existing structures and make relevant reforms, a needs assessment has to be done. This will assist in obtaining feedback from students on the strengths and weaknesses of traditional teaching methods, and the learning outcomes that such methods fail to meet. This study, therefore, serves to assess medical students’ perspectives on the learning outcomes of the teaching and assessment methods used in the anatomy course at the University of Zimbabwe. This will help in guiding the revision of its anatomy curriculum.

Methods

Local context

The University of Zimbabwe Medical School was established in 1963 as an affiliate of the University of Birmingham, UK. The university’s anatomy course is taught in three semesters during the first two preclinical years by the Department of Anatomy. Teaching is done by traditional didactic lectures, practical cadaver dissections, and group tutorials, while in the past 15 years the assessment has been done by multiple-choice-based end-ofregion tests and a final professional multiple-choice question examination at the end of the 2nd year. The curriculum has remained largely unchanged since the establishment of the medical school, despite major curriculum changes elsewhere in the world. A cross-sectional survey was carried out at the College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe between August and September 2014. A total of 1 063 medical students were registered with the college in the 2014 academic year – 208 students in the 1st year, 303 in the 2nd year, 225 in the 3rd year, 212 in the 4th year, and 115 in the 5th year. Stratified random sampling was used to choose the students who took part in the study to ensure that they were equitably distributed in accordance with the total number in each class relative to the total number of all students from the 1st to the 5th year of study.

MB ChB, year

Questionnaires distributed, n

Questionnaires returned, n (%)

Questionnaires disregarded, n

Questionnaires used, n

150

119 (79.4)

119

210

149 (71.0)

147

160

129 (80.6)

124

150

81 (54.0)

46 (57.5)

Total

750

524 (69.9)

502

Questionnaires (n=750) were distributed to the selected 1st-, 2nd-, 3rd-, 4th- and 5th-year medical students. The study instrument was a matrix questionnaire, which was divided into two sections. Section A elicited students’ year of study and gender. Section B assessed how well the three teaching methods (didactic lectures, cadaver dissections and tutorials) used in the anatomy course fitted a variety of teaching aims according to Moxham and Moxham.[6] The students were asked to choose a score between 0 and 5, where 0 represented no fit between the teaching method and the teaching aim and 5 represented a perfect fit (Table 1). Data were collected and entered into a computer. It was cleaned and analysed using the Stata statistical package version 13.0 (StataCorp., USA). Means and standard deviations (SDs) for the scores of each teaching objective for the three teaching techniques were calculated. The criteria designed by Moxham and Moxham,[6] shown in Table 2, were then used to assess the fitness for purpose of the mean scores between the teaching method and teaching aims. The mean scores for each teaching method were calculated for each teaching aim and the result was compared with the ratings (Table 2)[6] before a decision of whether the fit was excellent, good, moderate or poor was made and entered into a table.

Ethical approval

Ethical approval to conduct the study was obtained from the Joint Parirenyatwa Hospital and College of Health Sciences Research Ethics Committee, University of Zimbabwe (ref. no. JREC 172/14). Each participating student signed an informed consent form that outlined the objectives of the study, emphasising that participation was voluntary.

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Research Table 4. A completed matrix questionnaire Teaching methods Teaching aim

Lectures, mean (SD)

Cadaver dissections, mean (SD)

Tutorials, mean (SD)

All three methods, mean (SD)

1. To impart an anatomical foundation

3. 606 (1.180)

3.486 (1.319)

3.153 (1.575)

3.415 (1.380)

2. To provide background for clinical disciplines

3.337 (1.129)

3.078 (1.337)

3.088 (1.552)

3.167 (1.355)

3. To provide medical vocabulary

3.871 (1.078)

2.944 (1.373)

3.225 (1.504)

3.347 (1.385)

4. To appreciate anatomical variation

3.363 (1.212)

3.408 (1.435)

2.873 (1.535)

3.214 (1.420)

5. To relate structure to pathology

3.082 (1.257)

2.902 (1.427)

2.815 (1.540)

2.932 (1.416)

6. To provide student-directed learning

2.735 (1.424)

3.219 (1.446)

3.066 (1.638)

3.001 (1.518)

7. To develop team skills

2.339 (1.464)

3.488 (1.415)

2.735 (1.738)

2.854 (1.617)

8. To develop the ability to think and solve problems

2.616 (1.396)

2.735 (1.417)

2.978 (1.605)

2.776 (1.482)

9. To develop skills of following complicated instructions

2.719 (1.371)

2.898 (1.457)

2.416 (1.563)

2.731 (1.471)

SD = standard deviation.

Results

Of the 750 questionnaires distributed to the study participants, 524 were returned, giving a response rate of 70%. Twenty-two of the questionnaires were disregarded because they were incompletely filled out or the participants failed to follow the instructions. Only 502 questionnaires were used in the final analysis (Table 3). Table 4 shows the mean scores and SDs for the three teaching methods (lectures, cadaver dissections and tutorials) for the nine different teaching aims. The results of the fitness for purpose between the three teaching methods and the nine teaching aims are shown in Table 5.

Discussion

The results of this study showed that none of the three teaching methods had an excellent fit (mean >4.5) with the nine teaching aims. Cadaver dissection had a good fit with the teaching aims to develop team skills and to appreciate anatomical variation. In addition, it had a moderate fit with all the teaching aims, suggesting that this teaching method had the greatest ability to fulfil all the teaching aims. This supported earlier observations that cadaver dissection was the teaching method that could best achieve most learning outcomes desired in the anatomy course,[6] the reason being that cadaver dissection is able to build both the skills base and content base of students, both of which are important in anatomy.[4] However, the primary concern with cadaver-based learning is the difficulty in acquiring and maintaining enough cadavers.[5] This is notable in Zimbabwe, where the body donor programme has had a low uptake among black Zimbabweans. Furthermore, unclaimed bodies, a main source for anatomy cadavers, are usually decomposed when available for collection by the anatomy department. This is further compounded by the ethical and emotional worries associated with the use of human specimens for teaching purposes and the cultural implications of donating oneâ&#x20AC;&#x2122;s body for anatomy teaching.[5] When the individual learning outcomes were analysed, results indicated that lectures had a good fit with teaching aims related to content base, such as imparting an anatomical foundation and providing medical vocabulary. This is explained by the previous observations that didactic lectures are a good platform for teaching the basic language of anatomy to students.[3] Our results are also similar to those of a study of the perspectives of medical

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Table 5. Results of fitness for purpose of the three teaching methods and the nine teaching aims Rating Cadaver dissections

Lectures

Tutorials

1. To impart an anatomical foundation

Moderate

Good

Moderate

2. To provide background for clinical disciplines

Moderate

3. To provide medical vocabulary

Moderate

Good

Moderate

4. To appreciate anatomical variation

Good

Moderate

5. To relate structure to pathology

Moderate

6. To provide student-directed learning

Moderate

7. To develop team skills

Good

Poor

Moderate

8. To develop the ability to think and solve problems

Moderate

9. To develop skills of following complicated instructions

Moderate

Teaching aim

students on the relationship between course aims or learning outcomes and teaching methods.[6] Several teaching aims, however, were shown not to have a good fit with any of the teaching methods. These included provision of background for clinical disciplines, ability to relate structure to pathology, provision of student-directed learning, ability to think and solve problems, and acquisition of skills of being able to follow complicated instructions. The latter two teaching aims were shown to have the lowest mean scores of all the teaching aims. This can be explained by observations made in earlier studies, which showed that teaching of students using traditional methods was weak in integrating basic anatomy knowledge and practical situations in the clinic.[13,14] Moreover, basic science subjects were reported to be effective only to prepare students for assessments.[14] In addition, the students were reported to be passive learners, lacking initiative with regard to learning and applying anatomy knowledge.[13]

Research Conclusion and recommendations

The study indicated that traditional teaching methods are useful in imparting the content and skills base required in the anatomy course. However, there are some important teaching aims that are not being achieved by the methods used in the anatomy course at the University of Zimbabwe. These are mostly related to the ability to apply anatomy knowledge to clinical scenarios and to enhance the potential to think and solve problems. Therefore, modern teaching methods, such as PBL and TBL, should be incorporated in anatomy teaching to address these observed deficits. This combined approach to teaching and increased co-ordination among different basic and clinical departments might be the answer to a better understanding and application of anatomy knowledge in medical practice in Zimbabwe for the betterment of the health of the society. Acknowledgements. We would like to thank all the students who participated in the study. Author contributions. RS was involved in the conceptualisation, design, analysis and interpretation of the data. GM was involved in the design, analysis and interpretation of the data. RS drafted the initial version, and GM critically revised the content. RS and GM both approved the version submitted for publication. Funding. The Southern Africa Consortium for Research Excellence (SACORE). Conflicts of interest. None.

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Accepted 4 May 2017.

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Research

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

Clinical undergraduate medical student training at Kimberley Hospital, Northern Cape, South Africa: ‘A test of fire’ S Joubert, MB ChB, MMed (Int); V J Louw, MB ChB, MMed (Int), PhD (HPE) Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: S Joubert (joubertsunette@gmail.com)

Background. Medical schools in South Africa (SA) are challenged to increase the annual output of medical doctors. Satellite medical training campuses at remote public health facilities to expand the undergraduate clinical training platform may be a solution. Kimberley Hospital, Northern Cape, SA has been identified as a remote training site affiliated to the University of the Free State, Bloemfontein, SA. Objectives. To profile the clinicians at Kimberley Hospital Complex in terms of their knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training prior to the launch of the proposed undergraduate student rotations. Methods. The study followed a qualitative research design using semi-structured interviews with full-time SA- or foreign-qualified specialists at Kimberley Hospital Complex. Results. We identified the strengths and weaknesses of Kimberley Hospital, opportunities created for local healthcare providers, Kimberley town and the Northern Cape province, and threats to the success of the programme. Overall, responses were optimistic and depicted excitement about the new challenge. Conclusion. The perspectives of emerging clinician teachers at Kimberley Hospital Complex may serve as a point of reference for preparation of both clinician educators and programme administrators at the complex and other emerging satellite medical schools in the SA setting. Afr J Health Professions Educ 2017;9(4):180-184. DOI:10.7196/AJHPE.2017.v9i4.836

Medical schools in South Africa (SA) are challenged to recommend innovative cost-effective strategies to honour the ministerial directive of increasing the annual number of doctors trained in the country.[1] The intention is to address the disparity in healthcare services between urban and rural areas and, more explicitly, its associated morbidity and mortality.[2] One approach is to establish satellite medical training campuses at rural public health facilities to expand the undergraduate clinical training platform.[3] Kimberley Hospital Complex is a 657-bed tertiary healthcare facility in the Northern Cape, SA. The hospital employs 39 medical specialists, 14 of whom are foreign-qualified professionals. The available specialties are internal medicine, oncology, paediatrics, dermatology, emergency medicine, family medicine, radiology, intensive care, general surgery, obstetrics and gynaecology, anaesthesiology, orthopaedics, otorhinolaryngology, ophthalmology, urology, plastic surgery and burn unit, and cardiothoracic surgery. Clinicians are committed to continuous professional development, and structured academic programmes are followed in each clinical department. The hospital is affiliated to the University of the Free State, Bloemfontein, SA and is a Health Professions Council of South Africa (HPCSA)-accredited training institution. It hosts internship and registrar training programmes in several clinical departments. The Faculty of Health Sciences, University of the Free State, has earmarked Kimberley Hospital as a satellite clinical undergraduate medical student training site and spearheaded the facility’s HPCSA accreditation for undergraduate training. The first group of undergraduate students started their clinical rotation early in 2016. One of the major challenges facing institutions envisaging a new medical school is building a relationship with clinicians to ensure the provision of

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suitable clinical tutoring experiences for students.[4] The availability of the required range of clinical departments within potential healthcare facilities, and the aptitude and willingness to accommodate medical students in each of the required clinical domains, are equally important.[4] Expansion of the training platform also expects clinicians to perform the additional task of clinical student teaching over and above their health service delivery responsibilities.[5] During the 2014/2015 financial year, Kimberley Hospital served a total of 382 740 new patients at the specialised outpatient clinics, attended to 96 018 patients presenting to the casualty department, and managed 24 687 in-patients and 7 165 theatre cases (Ms Thembi Magabane – personal communication). Blitz et al.[6] retrospectively described the experience of emerging clinician educators at a local rural clinical school as a journey: starting from cautious optimism, through a period of uncertainty and insecurity as teachers, to fully fledged trainers enjoying the teaching experience and taking responsibility for their students’ successes. Students’ prior knowledge, how they organise knowledge, and their personal motivation influence what they learn, as well as how they apply and continuously practise acquired knowledge and skills. Through goaldirected practices and specific feedback, students become self-directed learners integrating their learning approaches with the intellectual, social and emotional aspects of an inclusive teaching environment.[7] The specialists at Kimberley Hospital are a diverse group of professionals with variable levels of clinical teaching experience. The specialist pool also comprises a mixture of SA- and foreign-trained professionals. It is therefore imperative to obtain a baseline profile of the potential clinician teachers at the institution.

Research This study aimed to profile the clinicians at Kimberley Hospital Complex in terms of their knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training before the launch of the proposed undergraduate student rotations in 2016. The results may serve as a point of reference for the preparation of clinician educators at Kimberley Hospital Complex and other emerging satellite medical campuses in the SA setting.

Methods

The study followed a qualitative research design and comprised semistructured interviews with full-time SA- or foreign-qualified specialists at Kimberley Hospital Complex. Written informed consent was obtained from participants prior to the interviews. Participants received the interview guide in advance to allow preparation for the interview. Discussions were digitally recorded, transcribed, coded and organised into broader themes pertaining to the perspectives of the upcoming clinician teachers at the institution.

Ethical approval

The study was conducted with the ethical approval of the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ref. no. ECUFS 102/2015) and the Northern Cape Provincial Health Ethics Review Committee (ref. no. NC2015/0021).

Results

The number in brackets next to the quotes given below refers to the respondent and ‘T’ indicates that the quote was translated from the original Afrikaans.

Demographic profile of interviewees

Twenty-seven of the 39 full-time specialists at Kimberley Hospital were interviewed during a 6-week period from September to October 2015. Interviews continued until data saturation was reached (i.e. no new information would be gathered by continuing interviews) and included at least one consultant of every discipline proposed to be involved in clinical student training. Community-based education relies heavily on family medicine; hence, all of the family medicine specialists were interviewed. Table 1 describes the demographic profile of the interviewees. Foreign qualifications were obtained in Cuba (n=5), Pakistan (n=3), Brazil, Ghana, Nigeria, Zimbabwe and Northern Ireland (n=1 each). Foreign-qualified specialists have a higher number of years of postgraduate experience. All but 2 SA interviewees spent their entire career in the public sector. The average number of weekly hours spent on undergraduate student training before employment at Kimberley Hospital ranged from 1 to 15 clinical bedside teaching hours per week. Only 2 of the 27 interviewees (7.4%) had experience in student assessment.

Results of the qualitative interviews

The overall perspective on the proposed undergraduate training programme in Kimberley Hospital was positive: ‘I am very excited. It is a good opportunity to influence the quality of doctors produced.’ (S9) ‘We have a good reputation, good potential trainers; it is doable, we can perform.’ (F3)

Table 1. Demographic profile of interviewees (N=27) Demographic parameter

Interviewees, n (%)

Respondent codes

Gender Male Female

20 (74) 7 (26)

14 (52) 6 (22) 7 (26)

S1 - S14 F1 - F6 C1 - C7

11 (41) 5 (18) 5 (18) 6 (22)

S = 8, C = 3 S = 3, C = 2 S = 2, C = 2, F = 1 S = 1, F = 5

Country where qualifications were obtained South African Foreign South African and foreign Postgraduate experience, years <5 5 - 10 11 - 20 >20

S = undergraduate and postgraduate qualifications were obtained locally; F = undergraduate and postgraduate qualifications were obtained abroad; C = undergraduate or postgraduate qualifications were obtained locally and abroad.

Twenty-two (81.5%) and 5 (18.5%) participants displayed overall positive and negative perspectives, respectively, on the proposed programme. All 5 interviewees who displayed apprehension towards the project were from one clinical department: ‘I’m not thrilled with the idea.’ (S3T) ‘I am not interested; I do not think we are ready for students.’ (S5) ‘It has no real benefit; you are taking time away from our patients.’ (C5)

Strengths of the institution

Interviewees expressed several strengths of Kimberley Hospital Complex. The hospital has an outstanding reputation and the specialist team is focused on quality, evidence-based patient care. Every department has an established academic and bedside clinical training programme. Students will receive ample exposure to pathology, personal attention and additional opportunities to develop clinical and practical problem-solving skills. Overall, the specialists find teaching rewarding: ‘It is rewarding if someone with no self-confidence develops into a doctor who can work independently in paediatrics. The day they start questioning my opinion, then I know I taught them to practise evidencebased medicine, to develop their own opinion and challenge current thinking.’ (S8T) ‘We can teach them the family medicine way of doing things. We see a lot of patients, if we do all the examinations in the department, it will increase our expense tremendously. You teach them to save costs. If you work in the primary healthcare setting, you need to know these things. You cannot go to the clinic and do a lot of special examinations; you will deplete the budget in no time. You need to decide what you are going to need to make a decision whether you must refer the patient at a certain stage. It is a skill you only learn when you pay attention in the department. The best place to learn is at the bedside; a student should see the patient, read up and come back to teach the entire group the next day.’ (C3) ‘We can teach them and show them the reality of casualties being overcrowded, bed management, theatre time, waiting times, overcrowded clinics. We can teach them to be proactive in problem-solving to improve the service.’ (F3)

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Research ‘ Students will be drawn into the team to teach them that everybody must work together to reduce hospital stay and get the patient back into the community.’ (S2T)

were busy teaching. Teaching as part of service delivery is fine for doctors, but students are a sacred, special group. The concept you teach them now must be correct – they will remember it for the rest of their lives. Their base should be sound and strong.’(C5)

Fig. 1 summarises the local specialists’ grasp of what good teaching entails.

Weaknesses of the institution

It became apparent that the interviewees were concerned about potential institutional weaknesses. Although the institution has a strong corps of specialists, the numbers of experienced medical officers and registrars are limited. Patient care relies heavily on interns, community-service doctors and medical officers in their first year after community service. Specialists have to be actively involved in service delivery to patients with tertiarylevel medical conditions. Our referral centre recently experienced severe financial and human resource constraints, reducing the number of patients our facility could refer for higher levels of medical care and hindering the referral centre’s outreach programme to Kimberley Hospital: ‘There must be enough people in the collective pool of consultants and permanent medical officers and time to teach. Service delivery will always take preference, but students cannot be neglected – you cannot miss a lecture. If some mishap happens it will be a problem; you cannot say you

Only 6 of the 27 interviewees admitted to having formal teaching qualifications and experience. They are foreign-trained specialists from Cuba and Brazil. Six other specialists indicated that they attended a recent short course for lecturers at the University of the Free State: ‘Teaching is an art, a skill; you need to be taught how to do it.’ (C3) None of the specialists has training in assessment methods: ‘We must initially observe assessments at the university. The university compares students; we will compare them to the interns in the ward when giving them ward marks. We may be too strict. Our measure will be whether they will be safe doctors if they return to Kimberley Hospital.’ (S1T) Other healthcare professionals, especially nursing staff, play a vital role in student teaching: ‘Our nurses are overworked and short staffed. Nowadays, it is difficult to get the nurses to join a ward round. It is not a good example to students; they learn you just go on with your round, write down and tell the nurse afterward what she must do.’ (F3)

Opportunities KNOWLEDGE

SKILL

ATTITUDE

• Up-to-date academic knowledge • Preventive medicine • Patient safety • Research and publishing • Generic teaching and assessment • Clinical teaching and assessment • Students’ baseline academic knowledge, performance and skills • Financial implications of medical care • Information technology • Equipment • Factors influencing student motivation • Public transport • Student accommodation • Recreational activities • Students’emotional readiness to become a doctor • Students’ personal and financial challenges

• Hands-on clinical skills • Probing and thorough; ‘There is always more than meets the eye’ (S8) • Focused, interesting, up-to-date clinical teaching skills • Integrate prior knowledge and skills • Immediate, constructive, goal-directed feedback • Fair and transparent assessment • Motivational skills • Clinical and organisational problemsolving skills • Structured and ideological communication skills • Breaking bad news • Inter-disciplinary teamwork • Cost-effectiveness • Time management • Emotional intelligence • Cultivate orderly, structured, well-equipped environment • Leadership

• ‘You need to feel it, you are here to save lives’ (F2) • Cultivates trust personally and academically, a mentor • General conduct in life: honest, ethical, respectful, humble, balanced, openminded, sincere, calm, fair • Approachable, patient, empathetic, sense of humour • Passionate, dedicated, dynamic, inspiring • Open to feedback and the students’ opinions • Teach by example • Interested in students’ backgrounds, know their names, empower them • Professional, punctual • Assertiveness and accountability • Dedicated, responsible, interested, curious and motivated students

The general opinion is that an academic environment, research and up-todate evidence-based medicine underscore service delivery: ‘Students are going to challenge us academically, ethically, in terms of work environment, the quality of what we are doing. You have to think twice about what you are doing because what I am doing is what I am teaching.’ (F3) Specialists will have the opportunity to gain teaching and assessment training and experience over and above their clinical expertise: ‘Skills to manage different varieties of students with different levels of academic performance and attitudes.’ (C3) Training sessions should preferably be periodic short courses presented in Kimberley by facilitators with undergraduate medical student training experience. Topics suggested were: the background to the current SA and Cuban student curricula, generic and medical teaching, and assessment techniques. Facilitators could also attend the local departmental academic sessions and ward rounds to give feedback about the quality to the consultants at Kimberley Hospital. This venture is the first step towards a medical school in the Northern Cape. The vision is to recruit specialists and registrars, train our own doctors, retain them in the province and ultimately enhance the accessibility of medical care in the Northern Cape: ‘I see it as a way to awaken interest in younger colleagues to offer their future services to our communities.’ (F2) ‘It will be a socioeconomic injection into Kimberley. Students drive smaller towns like Stellenbosch.’ (S6T)

Threats to the programme Fig. 1. Summary of specialists’ grasp of what good teaching entails.

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Interviewees expressed their concern about threats to the proposed undergraduate programme. The main threat identified was balancing

Research quality patient care with quality student training, specifically pertaining to time and human resources. The hospital has a high turnover of medical officers, mostly because they move into registrar posts elsewhere in the country. The core workforce remains inexperienced, demanding continuous consultant supervision and involvement to ensure quality tertiary service delivery. Some departments have only one consultant; the programme may be jeopardised if the specialist resigns. It is very difficult to compete with academic institutions, the private sector and other more popular provinces in terms of recruitment and retention of specialists. Furthermore, financial pressures in the public sector preclude the creation and funding of additional senior medical officer and specialist posts: ‘I will have less time with my patients and it may compromise patient care. We need registrars to assist with the workload and service delivery. We need more subspecialists to assist with training.’ (S5) ‘You have to look for patients with clinical signs; this takes time.’ (C5) Active clinical and academic support from our referral hospital and specialists at the main campus through outreach and in-reach programmes is imperative: ‘We are not an island; we are an extension of their academic departments.’ (S6T) The venture demands strong leadership and continuous buy-in of stakeholders in the Free State and Northern Cape departments of health, the University of the Free State and the Kimberley satellite campus. Our specialists’ motivation to invest teaching time relies heavily on the baseline standard of clinical knowledge, skills and attitude of the students rotating at Kimberley for their clinical training: ‘It is better to teach someone with sound baseline knowledge than a student who doesn’t know anything. I am worried about the Cubantrained students. They need special attention. We do not have time to motivate and support struggling students. The pace is too fast here; they will fall behind.’ (S1T) Some junior doctors’ attitudes towards patients, colleagues, nursing staff and the profession are occasionally disrespectful and unprofessional: ‘Their etiquette, they are role models.’ (F3)

Student selection

Although student participation is voluntary, certain minimum selection criteria are important. A student’s motive for choosing the satellite campus must ideally be determined by an interview process. The ideal student is independent, self-disciplined, resilient, committed, responsible, hardworking and reliable: ‘If we take the top students, obviously they will do well and we did not actually achieve that much because we started with the best. Achievement would be if you take the average student, say 60% to 65%, and try to mould him into a top achiever or over 70%. The group must be small. A guy who has the ability to the top might have a better chance when he is part of a small group. The top achiever’s chance to return to the Northern Cape is slim; they specialise and super-specialise and stay in the main hubs.’ (S10) Students must be prepared to accept foreign-trained specialists as teachers and English as the language of tuition:

‘ I am worried that students will not accept me as a foreign-qualified specialist.’ (F3) In terms of demographics, ‘rural origin’ should not be a selection criterion. Students from the Northern Cape, especially Kimberley, have a logistical and financial advantage, but allowing students from other provinces into the programme may be a marketing strategy to recruit future doctors into the province.

Other considerations

Findings show that piloting of the project in the family medicine department is the ideal objective: ‘Piloting the project will make us more comfortable with the expectations and give us opportunities for feedback on the logistical abilities of our clinics; how much time and resources are necessary.’ (C4) Transport of students to and from clinics, the psychiatric unit, Kimberley Hospital, and the student residence must be well co-ordinated: ‘Administrative office space for specialists and secretarial support with internet connectivity to prepare assessments, load marks, making sure it is correct is crucial’. (S7) End-of-block assessments should take place in Kimberley, but the final exit examination must still be hosted at the main campus. The Kimberley consultants must have the opportunity to submit questions for the written examination papers: ‘People must feel they are part of this new challenge and new way of doing things.’ (S11) ‘Briefing of all medical personnel at Kimberley Hospital and the district clinics is very important. The nurses at clinics must also give feedback on the number of students they can accommodate.’ (C4)

Discussion

Medical schools in SA are challenged to recommend cost-effective strategies to increase the annual number of doctors trained in the country.[1] The intention is to address the disparity in healthcare services between urban and rural areas and its associated morbidity and mortality.[2] One approach is to establish satellite medical training campuses at rural public health facilities.[3] A major challenge is building a relationship with clinicians to ensure the provision of suitable clinical tutoring experiences for students.[4] The availability of a range of clinical departments within potential healthcare facilities, and an aptitude and willingness to accommodate medical students, are important.[4] This study aimed to profile the clinicians at Kimberley Hospital Complex in terms of their knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training. The overall perspective on the proposed undergraduate training programme at Kimberley Hospital was positive. The apprehensive clinicians were from one department, their main concern being the lack of senior medical officer and registrar support in the particular department.

Study strengths

Strengths identified were: academically inclined clinicians motivated to teach students the realities of clinical medicine, teamwork, critical thinking and problem-solving skills. They have strong opinions about the concept of good

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Research teaching. The limited number of senior healthcare professionals draws specialists and nurses into front-line service delivery; hence, the added responsibility of student training and assessment will be a challenging balancing act.

Study limitations

The relative inexperience of the respondents regarding this particular subject may be seen as a limitation to the study. One must keep in mind that the study aimed to assess the clinicians’ knowledge of, skills in and perspectives on the added responsibility of clinical undergraduate medical student training. Moreover, at the time of the study, the specific semester or year of clinical study was not yet finalised. This information could potentially have influenced the interviewees’ responses.

Conclusion

This venture was the first step towards a Northern Cape-based medical school that trains healthcare professionals from the province and for the province. Ultimately, it should improve accessibility to quality medical care and provide a socioeconomic injection into Kimberley and the province. It is also a personal and professional career opportunity for local specialists to become more proficient in teaching and assessment methods and may be an important recruitment and retention strategy. If the teaching of medical students is instituted in a rural area, it may also be an alternative option and perhaps a drawcard for specialists who are interested in teaching and would like to live and work in a more rural environment. The success of the proposed satellite medical campus relies heavily on buy-in from key role-players in Kimberley Hospital, the Northern Cape districts, the University of the Free State, as well as national and provincial executive and financial stakeholders.

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The perspectives of emerging clinician teachers at Kimberley Hospital Complex may serve as a point of reference for preparation of clinician educators and programme administrators at Kimberley Hospital Complex and other emerging satellite medical schools in the SA setting. As one of the respondents indicated, ‘The first group will be the most difficult: a test of fire. We must work on our mistakes and prepare for the next group. We will get better and better.’ Acknowledgements. The authors acknowledge Prof. G J van Zyl, dean of the Faculty of Health Sciences, University of the Free State, for his valuable inputs in the writing of the manuscript. Author contributions. SJ and VJL: cultivated the idea and methodology of the research; SJ: performed the data processing and wrote the article; and VJL: conducted the final checking, inputs and improvement of the discussion section. Funding. None. Conflicts of interest. None. 1. Health-e News. Motsoaledi shares his plans. South African Health News Service, 5 October 2012. http://www. health-e.org.za/2012/10/05/motsoaledi-shares-his-plans (accessed 29 September 2017). 2. Harris B, Goudge J, Ataguba JE, et al. Inequities in access to health care in South Africa. J Publ Health Pol 2011;32:S102-S123. https://doi.org/10.1057/jphp.2011.35 3. Bateman C. Academics appeal to State: ‘Help us train where the needs are’. S Afr Med J 2011;101(8):498-500. https://doi.org/10.7196/SAMJ.5121 4. Whitcomb ME. New and Developing Medical Schools: Motivating Factors, Major Challenges, Planning Strategies. New York: Josiah Macy Jr Foundation, 2009:1-84. 5. Levinson W, Branch WT, Kroenke K. Clinician-educators in academic medical centers: A two-part challenge. Ann Intern Med 1998;129(1):59-64. https://doi.org/10.7326/0003-4819-129-1-199807010-00013 6. Blitz J, Bezuidenhout J, Conradie H, de Villiers M, van Schalkwyk S. ‘I felt colonised’: Emerging clinical teachers on a new rural teaching platform. Rural Remote Health 2014;14:2511. 7. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK. How Learning Works: 7 Research-Based Principles for Smart Teaching. San Francisco: Jossey-Bass, 2010:1-6.

Accepted 3 May 2017.

Research

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

Designing interprofessional modules for undergraduate healthcare learners C Maree,1 PhD; P Bresser,2 MRad; M Yazbek,1 DCur; L Engelbrecht,3 MOccTher; K Mostert,4 PhD; C Viviers,5 MDiet; M Kekana,2 MTech (Ed) 1

Department of Nursing Science, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Radiography, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Occupational Therapy, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Physiotherapy, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, South Africa

Department of Human Nutrition, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, South Africa

Corresponding author: C Maree (carin.maree@up.ac.za)

Background. Interprofessional education aims to prepare learners to collaborate across specialties to provide high-quality healthcare. Internationally and nationally, the emerging need for integrated healthcare and education has been emphasised. The current education programme at the School of Health Care Sciences, University of Pretoria, South Africa primarily follows a uniprofessional approach. Objectives. To describe the development of interprofessional modules over 4 years between the departments of Human Nutrition, Nursing Science, Occupational Therapy, Physiotherapy and Radiography. Methods. The Knowledge-to-Action model guided the module development process. The planning phase comprised three steps: (i) problem identiÂ fication (e.g. national and international policy focus on interprofessional education); (ii) review of existing knowledge (e.g. common learning outcomes); and (iii) adaptation of knowledge to the local context (e.g. syllabi and logistics). Results. The development of interprofessional modules can be guided by the above-mentioned model to meet the needs of the faculty, departments, students and community and to contribute to interprofessional education, while overcoming the associated challenges. Conclusion. Challenges included clashes in timetable schedules, financial constraints, administrative support, logistical issues and resistance to change. The designing and implementing of new modules were intense and time consuming, and required commitment. The development of the modules was an excellent example of interprofessional teamwork that needs to be transferred to the implementation and role modelling of interprofessional education. Afr J Health Professions Educ 2017;9(4):185-188. DOI:10.7196/AJHPE.2017.v9i4.853

Globally, interprofessional education is lauded for its potential to improve the quality of healthcare and healthcare outcomes by teamwork between professionals from various health-related disciplines.[1] Furthermore, healthcare professionals need to meet the demands of the community and the country, which are caused by the burden of complicated disease.[2] In South Africa (SA), the Department of Health is re-engineering primary healthcare, advocating a strategy of multidisciplinary teamwork in the community.[3] Healthcare professionals from different disciplines or professions work together to achieve a common goal within a multidisciplinary team, sharing some common roles, e.g. professionalism, leadership and advocacy.[4] Interprofessional education may address the lack of multidisciplinary teamwork in healthcare settings. Traditionally, undergraduate education has focused on a professional specialty, with limited exposure to teamwork between healthcare professionals. Interprofessional education therefore aims to prepare learners to collaborate across specialties to provide high-quality healthcare.[5] The School of Health Care Sciences at the University of Pretoria, SA has traditionally followed a uniprofessional educational approach. The emerging need for interprofessional healthcare education was identified as a gap in the undergraduate education programme. As part of mandatory curriculum revision, the departments of Human Nutrition, Nursing Science, Occupational

Therapy, Physiotherapy and Radiography identified the opportunity to incorporate interprofessional education as part of their programmes. The School of Health Care Sciences identified two areas with potential for interprofessional education, i.e. research and integrated healthcare leadership. The objective of this article is to describe the approach and process followed in developing integrated healthcare leadership modules for interprofessional education that benefit the community and to achieve the educational outcomes of the five undergraduate healthcare programmes.

Methods and Results

We used the Knowledge-to-Action cycle (Fig. 1) to guide and focus important tasks associated with designing and implementing the interprofessional module.[6] The Knowledge-to-Action framework incorporated information from individuals or teams from diverse contexts. This framework permitted focusing on local context and practice when adapting and implementing the interprofessional module; it fragmented the process from inception to implementation into manageable components and provided a structure and rationale for the activities involved in each phase of development.[ 6] We report on Phase 1 of the Knowledge-to-Action model, which encompasses the planning phase (Fig. 1). We describe the process of identification

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Research training. The interprofessional healthcare leadership modules were first introduced in 2015 at 1st-year undergraduate level – to be offered over consecutive years.

Identify problem

• Evaluate logistic implications • Proposal for academic planning • Incorporation into Product revised curricula tools

2. Select, tailor and implement interventions PHASE 2 – PRE- AND POST IMPLEMENTATION

1. Identify problem 2. Review knowledge 3. Adapt knowledge to local content

Knowledge enquiry Synthesis Product tools

G NIN AN – PL

is Synthes

PHASE 1 – PLANNING

SE 1 PHA

Review • Evaluate common ELOs and knowledge graduate attributes • Consolidation to define learning outcomes Adapt • Synthesis into interprofessional knowledge module to local context

1. Assess barriers and supports

Tail orin g kn PHA owle SE 3 dge – EV ALU ATIO N

Know le enqu dge iry

• Need for undergraduate IPE

1. Monitor knowledge use 2. Evaluate outcomes 3. Sustain knowledge use

Fig. 1. Knowledge-to-Action cycle. (IPE = interprofessional education; ELO = exitlevel outcome.)

of problems, review of existing knowledge and adaptation of the knowledge to the local context. The results of each phase are integrated in the description of each respective phase.

Knowledge enquiry: Identify need

The need for interprofessional education was identified at the strategic planning session of the School of Health Care Sciences. We identified the opportunity to revise undergraduate curricula to meet important healthcare needs. The Teaching and Learning Committee was mandated to establish a task team(s) with representation from all five departments aimed at determining the potential of such modules and the way forward. Two task teams were established, focusing on research and integrated healthcare leadership. (The process followed for the research module will be reported in a separate article.)

Synthesis: Review knowledge

The task team for integrated healthcare leadership used the Knowledgeto-Action model to guide the process. The initial team consisted of six members, with an additional member added soon after initiation (Table 1). The curricula and professional board regulations of the five professions were included in the knowledge review. Content was systematically unpacked to identify common exit-level outcomes and graduate attributes. The common exit-level outcomes were consolidated in table format to facilitate comparison of different professions. Potential learning outcomes for interprofessional modules were synthesised and captured.

Product tools: Adapt knowledge to local context

The proposed interprofessional modules were presented to the School of Health Care Sciences’ executive management and academic staff; discussions focused on content, and financial and logistical implications. A proposal outlining the implementation and incorporation of the interprofessional modules was drafted for submission to the Academic Advisory Committee and Faculty Board of the Faculty of Health Sciences. On approval of the submission, two sub-committees were established (Table 1) that were tasked with collating and designing learning material and learner guides for the respective interprofessional modules. These modules are incorporated in the first 3 years of undergraduate training of healthcare professionals, with complementary profession-specific modules in alternate semesters (Table 2) and the final year of undergraduate

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Discussion

Interprofessional education is aimed at creating an environment where future healthcare professionals can learn to collaborate, improving knowledge, skills and attitudes that will increase the wellbeing of patients and clients.[5] It can either commence early in professional training or after the unique aspects of professional training have been completed.[5] Often students complete their studies independently and shared learning only takes place during clinical exposure. Where education occurs in isolation, healthcare students may develop preconceived ideas and biases towards other professions before entering a multidisciplinary clinical environment.[7] It was therefore decided that the integrated healthcare leadership module be introduced from the 1st year to the 3rd year of study (Tables 1 and 2). Interprofessional education promotes competent and responsible collaborative teamwork. Members need to understand ethics, roles and responsibilities of team members and communication.[8] Interprofessional education in the School of Health Care Sciences started with collaboration among the academic staff members from the five different professions, and this may build confidence in a personal and professional capacity. The task team experienced increased collaboration and collegiality, which is in line with the report from Pirrie et al.[9] that group work may lead to improved task achievement as a team and develop critical reflective practice. The impact will be monitored and reported on in due course. As these modules were new in our school, we had to consider educational design before implementing a shared education programme. We included a needs assessment; clear measurable learning objectives; outcomesbased curriculum design; interactive teaching methods; and an evaluation typology. The task team had to consider individual context, environment and university systems. It also had to incorporate the requirements of professional bodies that uphold standards and unique cultures of the respective professions, while simultaneously promoting interprofessional health team concepts.[9] During programme development we had to ensure that the interprofessional team was able to deal with resistance to implementation of the programme.[10] Our group included a front-line healthcare team, health professional educators, administrators, managers and policy makers. Interprofessional education is challenging and a prepared team of educators is scarce.[2] Our strategic mission had to be all embracing and relied on educators committed to identifying learning opportunities. We faced logistical problems, including clashes in timetable schedules, financial constraints, and lack of administrative support and role models. We also experienced an inability to recognise the value of interprofessional education, resistance to change and an inflexible curriculum.[7,8] We took the theory of constructive alignment into consideration to ensure that there is alignment between the outcomes, assessments and learning activities, as described by Biggs and Tang.[11] Authentic learning, as set out by Leppisaari et al.,[12] was also kept in mind, especially the emphasis on the need for a supportive collaborative construction of knowledge. In developing the interprofessional modules, the emphasis on integrated teams was ensured through group projects that are undertaken by students from different professional groups.

Research Table 1. Process of development of interprofessional modules Steps

Key activities

Reality of process

Knowledge enquiry: identify problem

Need for undergraduate IPE identified at strategic planning session of the SoHCS

The need to incorporate interprofessional modules (also referred to as ‘shared modules’) in undergraduate healthcare education and training was identified at a strategic planning session of the SoHCS. The Teaching and Learning Committee had to explore the potential of implementing interprofessional modules. Two streams were identified for possible interprofessional teaching and learning through discussion and debate of potential themes, and task teams were identified as follows: (i) The task team for development of an integrated healthcare leadership module(s) consisted of members from all departments: Department of Human Nutrition – 1 representative Department of Nursing Science – 1 (chairperson) + 1 representative Department of Occupational Therapy – 1 representative Department of Physiotherapy – 1 representative Department of Radiography – 2 representatives (ii) A separate task team was identified for development of an interprofessional module(s) in research, which is not reported on in this article. Choice of representatives for the task teams was informed by members’ various roles within departments and expertise in specific subject areas or their roles in the curriculum review process of their department.

Synthesis: review knowledge

Evaluate common ELOs and graduate attributes

The task team met on scheduled dates. First meeting: the ground rules and approach to be taken in developing the modules were determined. Decisions included that the shared modules should be presented as core modules in all academic years; there should be team teaching; and the focus should be on community-based healthcare. Second meeting: members from the respective departments each compiled a list of ELOs and graduate attributes that might be of generic nature for each profession. The ELOs and graduate attributes were retrieved from the profession’s regulatory bodies. Data were collated and presented in table format to make comparison between professions easier.

Consolidate to define learning outcomes for IPE

Third and fourth meetings: the ELOs were discussed until consensus on the potential generic outcomes was reached and the profession-specific outcomes were eliminated. A decision was made to have profession-specific and interprofessional modules in alternate semesters for each year (Table 2). Fifth and sixth meetings: possible study themes were informed by the generic profession outcomes, and attributes were identified for scaffolding over the different academic years.

Evaluate logistical implications

Seventh meeting: a layout of the modules over the consecutive academic years was presented to the executive committee and staff members of the SoHCS. Logistical implications were discussed, including human resources, timetable and venue implications, and administrative aspects. Two sub-committees were established, with representation from all departments, to develop the details of the learning material for the 1st-year module for 2015 (10 lecturers) and 2nd-year module for 2016 (10 lecturers). The third sub-committee was established in 2016 to develop details of the learning material for the 3rd year to be rolled out in 2017 (6 lecturers). The initial task team members formed part of the sub-committees.

Proposal for academic planning

Eighth meeting: refinement was made to proposed modules as suggested and decisions were made regarding the writing of the proposed regulation changes. Two task team members wrote the proposed regulation changes and distributed the document to the other task team members and the executive committee. The proposed regulation changes then followed the process according to internal policy: head of student administration, academic planning department, academic advisory committee, and faculty board and senate.

Incorporation into revised curricula

Once the regulation changes had been approved, the respective departments incorporated the new modules as a core subject in their curricula. The first introduction of the modules took place in 2015 in the departments of Human Nutrition, Occupational Therapy and Physiotherapy. The departments of Nursing Science and Radiography will introduce them with the roll-out of their new curricula. Monthly: 2-monthly meetings followed to discuss challenges, achievements and logistics. An additional outcome was that the Department of Speech and Language Pathology joined the process in 2016, with their first group of students enrolling for the modules in 2017.

Product tools: adapt knowledge to local context

IPE = interprofessional education; SoHCS = School of Health Care Sciences; ELO = exit-level outcome.

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Research Table 2. Locating the interprofessional modules within curricula Year

Semester 1

Semester 2

1st, NQF level 5

Uniprofessional module: introduction to respective professions*

Interprofessional Health Leadership I: teamwork and communication in the community health setting (8 credits)

2nd, NQF level 6

Interprofessional Health Leadership II: principles of community health project development and health literacy (8 credits)

Uniprofessional module: complementary content determined by each discipline*

3rd, NQF level 7

Interprofessional Health Leadership III: community-based project (8 credits)

Uniprofessional module: complementary content determined by each discipline*

Interprofessional Healthcare Research III: proposal development (30 credits) 4th, NQF level 8

Uniprofessional module: content determined by each discipline*

Interprofessional Healthcare Research IV: research project (10 credits) NQF = National Qualifications Framework. *Credits differ for respective disciplines.

Conclusion

Effective interprofessional healthcare may alleviate service duplication, miniÂmise interventions and reduce healthcare costs. Educators need to work together to create opportunities for shared learning to improve interprofessional teamwork. Designing and implementing new modules is intense and time consuming and requires commitment. Although various models of interprofessional education in the community have been reported, this article focuses on the application of a structured framework to describe the process followed in the development of interprofessional healthcare modules at undergraduate level. The process was an excellent example of interprofessional teamwork, which needs to be transferred to implementation and role modelling with regard to the designing of interprofessional education opportunities for the healthcare professions. Acknowledgements. The authors wish to extend their appreciation to the following individuals for their contribution to the development of the modules: Prof. M Mulaudzi, Drs V Bhana-Pema, Z White, S Mataboge, R Ngunyulu, S Phiri, Mmes G Lovric, M Sethole, Ms H van Wyk, and Mrs M Cochrane-Booyens. The authors also acknowledge Dr C Tosh for editing this manuscript. Author contributions. All authors contributed to the conceptualisation and writing of the publication. PB did the technical editing. Funding. All costs were absorbed by the operational budgets of the departments. Conflicts of interest. None.

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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. World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: WHO, 2010. 3. Pillay Y, Barron P. The implementation of primary healthcare re-engineering in South Africa. 2011. http://www. phasa.org.za/the-implementation-of-phc-re-engineering-in-south-africa/ (accessed 10 October 2017). 4. Rawson D. Models of interprofessional work: Likely theories and possibilities. In: Leathard A, ed. Going Interprofessional. Working Together for Health and Welfare. London: Routledge, 1994. 5. Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: Effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev 2013;(3):CD002213. https://doi. org/10.1002/14651858.cd002213.pub3 6. Graham ID, Tetroe JM. The knowledge to action framework. In: Rycroft-Malone J, Bucknall T, eds. Models and Frameworks for Implementing Evidence-Based Practice: Linking Evidence to Action. West-Sussex: WileyBlackwell, 2010:207-221. 7. Dufrene C. Health care partnerships: A literature review of interdisciplinary education. J Nurs Educ 2012;51(4):212-216. https://doi.org/10.3928/01484834-20120224-01 8. Murphy SA. Interdisciplinary education in the addictions: A commentary on the current status. J Addict Nurs 2013;24(1):4-7. https://doi.org/10.1097/jan.0b013e31828767b7 9. Pirrie A, Wilson V, Harden RM, Elsegood J. Promoting cohesive practice in health care. AMEE Guide No. 12: Effective multiprofessional education â&#x20AC;&#x201C; a three dimensional perspective. Multiprof Educ 2000:14-22. 10. Waggie F, Laattoe N. Interprofessional education and practice: Two community-based models. In: Tolken AS, ed. Service Learning Across the Globe: From Local to Transnational. Proceedings of the 5th International Symposium of Service-Learning, 20 - 22 November 2013, Stellenbosch, South Africa. https://www.sun.ac.za/english/ci/ service-learning/issl (accessed 10 October 2017). 11. Biggs J, Tang C. Teaching for Quality Learning at University. What the Student Does. 3rd ed. London: Society for Research into Higher Education and Open University Press, 2007. 12. Leppisaari I, Herrington J, Vainio L, Im Y. Authentic e-learning in a multicultural context: Virtual benchmarking cases from five countries. J Interact Learn Res 2013;24(1):53-73.

Accepted 4 April 2017.

Research

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

Learning outcomes of occupational therapy and physiotherapy students during their community-based education attachment T Ndlovu, BSc, HPT; T M Chikwanha, MPH, BSc (HOT); N Munambah, MSc (OT), BSc (HOT) Department of Rehabilitation, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe Corresponding author: T M Chikwanha (middychiky@yahoo.co.uk)

Background. Community-based education (CBE) is a learning approach that enables students to acquire skills by means of applied learning in the community. The goals of CBE include creating adequate knowledge, skills and attitudes that facilitate service delivery in communities. These goals ensure the provision of efficient health services to marginalised communities with significant resource constraints. The Department of Rehabilitation at the University of Zimbabwe, Harare, has adopted CBE as one of the learning approaches that enables students to acquire comprehensive skills for future service provision in the community. Objectives. To determine the learning outcomes of rehabilitation students at the University of Zimbabwe and to identify factors affecting learning during the CBE attachments. Methods. A descriptive cross-sectional survey was conducted at the University of Zimbabwe. Thirty-five final-year occupational therapy and physiotherapy students responded to a self-administered questionnaire. Data were analysed using Microsoft Excel 2013 (USA) and SPSS version 21 (IBM Corp., USA). Results. All the students reported that the CBE attachment improved their community-engagement skills, professional skills and personal growth. Barriers to effective learning included inadequate transport (100%), poor internet connectivity (82%), lack of research-related objectives (74%) and inadequate resources for CBE activities (60%). Conclusion. The CBE attachment enabled students to gain skills in community engagement, professionalism and personal growth. However, more funding directed towards CBE activities and introducing objectives related to research, are some of the strategies that might improve the studentsâ&#x20AC;&#x2122; learning outcomes during the attachments. Afr J Health Professions Educ 2017;9(4):189-193. DOI:10.7196/AJHPE.2017.v9i4.958

Community-based education (CBE) is a learning approach that enables students to acquire skills by means of applied learning in the community.[1] This learning approach includes elements of primary healthcare, health promotion and disease prevention, and allows students to acquire clinical, research, communication and other professional competencies in a commuÂnity setting.[2] The goals of CBE include creating knowledge, skills and attitudes among students to ensure the provision of efficient health services to marginalised communities, often in rural areas and communities with significant resource constraints.[3] These goals ultimately increase health professionalsâ&#x20AC;&#x2122; willingness to work in underserved areas.[4] CBE provides opportunities to acquire research, clinical and public health skills through applied learning in a community setting.[1] The objective of CBE is to direct health professionals towards the most important health problems of the community.[5] Despite the several challenges that may affect CBE, lower attrition rates, a greater perceived ability to function in rural communities and high satisfaction, as indicated by students and community members, have been noted as advantages of CBE.[6] Other beneficial aspects of CBE include early contact with the community, improved teamwork of trainees, and improved interpersonal relationships and communication skills.[6] The physiotherapy and occupational therapy students at the University of Zimbabwe, Harare, have been part of CBE attachments since the inception of the programmes in 1987. The University of Zimbabwe has 12 CBE attachment sites,

which are shared by all the programmes of the College of Health Sciences. The activities at each of the CBE sites differ, depending on available resources. These activities are mainly sponsored by the Ministry of Health and Child Care and its partners. The University of Zimbabwe provides transport for the students during the CBE attachment. Each of the attachment sites can accommodate a maximum of 10 students; therefore, the number of attachment sites per given year is determined by the number of students registered for their 3rd year in both physiotherapy and occupational therapy. The students who participated in this study had been attached to 5 of these 12 sites. Before their CBE attachment, the students in the Department of Rehabilitation at the University of Zimbabwe receive lectures to prepare them for the attachment. Some of the content covered during the lectures includes the role of rehabilitation professionals in the community, developing, monitoring and evaluating community-based rehabilitation programmes, as well as managing and administering rehabilitation units. These lectures provide the students with the theoretical learning experience, while the CBE attachments provide a practical learning experience. The students are placed at CBE attachment sites for 6 weeks in teams comprising occupational therapy and physiotherapy students. As part of the attachment, the students are expected to visit the local leadership, such as chiefs, headmen, councillors and traditional healers, before conducting any rehabilitation intervention in the community. They are also

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Research expected to participate in management and administration activities in the rehabilitation departments. The students are supervised by rehabilitation staff in the districts where they are attached. In addition, the faculty from the Department of Rehabilitation conduct a once-off mid-attachment evaluation for each of the sites. For the training curriculum to remain relevant in the context of CBE, there is a need to continuously evaluate learning outcomes for students. This study was conducted to determine the learning outcomes, barriers and facilitators to effective learning of physiotherapy and occupational therapy students at the University of Zimbabwe during their CBE attachment.

Methods

A descriptive cross-sectional study was conducted in the Department of Rehabilitation, College of Health Sciences, University of Zimbabwe. The university is currently the only institution that trains physiotherapists and occupational therapists in Zimbabwe, with an average enrolment of 40 per year for both. Guided by the objectives of the CBE attachment and insights from the literature, the researchers developed a self-administered questionnaire that was used in the study. This questionnaire had three sections. Section A collected demographic information. Section B consisted of 20 questions related to students’ learning outcomes during the CBE attachment. These questions were further divided into three subsections, i.e. community engagement, professional skills and personal growth. Community engagement was defined as the cognitive, affective and behavioural outcomes related to community participation.[7] Professional skills were described as techniques, behaviours and attitudes that enhance efficacy in the workplace.[7] Personal growth was defined as affective outcomes related to understanding oneself.[7] Community engagement was assessed using 6 questions, professional skills were assessed using 10 questions and personal growth was assessed using 4 questions. The responses to the questions that assessed the learning outcomes were rated on a 4-point scale: 1 = not at all, 2 = minimally, 3 = moderately, and 4 = extensively. Section C assessed the barriers to CBE and the possible strategies for improving learning experiences during the attachment. This section had closed-ended questions with ‘yes’ or ‘no’ responses. Validation of the questionnaire was done in two stages. Firstly, the questionnaire was given to a panel of experts who included physiotherapy and occupational therapy lecturers responsible for the CBE programme. After revising the questionnaire based on the feedback from the panel of experts, a pilot study was conducted with 20 of the physiotherapy and occupational therapy students who had graduated from the University of Zimbabwe in 2015. The data from the pilot study were then analysed and redundant questions were removed. The study sample comprised 35 occupational therapy and physiotherapy students who had just started the first semester of their final year. An overview of the study and its objectives was presented to these students before the self-administered questionnaires and consent forms were distributed. Students who were willing to participate were asked to sign the consent forms first and complete the questionnaire, which they had to drop into a box in their lecture room within 1 week. No names or student identification numbers were recorded on the questionnaires. Data were entered into Microsoft Excel 2013 (USA) and analysed using SPSS version 21 (IBM Corp., USA). Sociodemographic characteristics were analysed for means and frequencies. Students’ level of community engagement was scored out of a maximum possible score of 24 and a minimum possible

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score of 6. Professional skills were scored out of a maximum possible total of 40 and minimum possible score of 10. Personal growth was scored out of a maximum possible score of 16 and a minimum possible score of 4. Total expected scores on community engagement (24), professional skills (40) and personal growth (16) were added to give the expected overall learning outcome score of 80. The overall learning outcome score for each of the students was obtained by expressing the total scores from each of the three subsections as a percentage of the overall expected learning outcome score. Perceived barriers were grouped into three categories, i.e. administrative challenges, personal barriers and financial challenges, and were presented as frequencies. Strategies to facilitate students’ learning during the CBE attachment were also expressed as frequencies.

Ethical approval

Permission to carry out the study was requested from the dean, College of Health Sciences, University of Zimbabwe. Ethical approval was sought from the Joint Research Ethics Committee (ref. no. JREC/253/15) and from the Medical Research Council of Zimbabwe (ref. no. MRCZ/B997).

Results

All 35 final-year students participated in the study. The mean age of participants was 22 (standard deviation (SD) 0.97) years. Twenty-three (65%) of the participants were female and 12 (34%) were male. Twenty-one (60%) participants were physiotherapy students and 14 (40%) occupational therapy students. Six (17%) students were attached in district 1; 7 (20%) in district 2; 8 (23%) in district 3; 7 (20%) in district 4; and 7 (20%) in district 5. (Note that the actual names for the districts were replaced with numbers for confidentiality purposes.) Students’ self-reported learning outcomes of the CBE attachments are given in Table 1.

Community engagement

All students had an opportunity to learn about community engagement during their CBE attachment (Table 1). All of them reported that the CBE attachment had enhanced their understanding of community issues pertaining to rehabilitation, facilitated their understanding of clients in need of rehabilitation services, and improved their understanding of the organisation of rehabilitation services at community level. They also learnt how to conduct health education talks and provide outreach services.

Professional skills development

The students generally reported that the CBE attachment had given them an opportunity to improve their professional skills (Table 1). The majority (97%) reported that their learning experiences had helped them to interact with other health professionals in patient care and enhanced their conflict-resolution skills. All the students reported that the attachment had improved their public speaking skills and their ability to work as part of a team. The attachment also improved the ability of 24 (68%) students to work independently. With regard to the development of management skills, most (91%) of the students reported that the CBE attachment had improved their ability to run meetings, delegate tasks and respect the opinions of others when working as a team. Nineteen (54%) of the students indicated that the CBE experience extensively improved their understanding of the roles of other rehabilitation staff. Twelve (34%) of the participants indicated that the CBE experience extensively improved their understanding of how to manage a rehabilitation department.

Research Table 1. Studentsâ&#x20AC;&#x2122; learning outcomes of the CBE attachment Not at all, n (%)

Minimally, n (%)

Moderately, n (%)

Extensively, n (%)

Enhanced my understanding of community issues

0 (0)

3 (9)

13 (37)

19 (54)

Will likely enhance my future community engagement

2 (6)

13 (37)

18 (51)

Facilitated my understanding of clients in need of rehabilitation services

1 (3)

2 (6)

13 (37)

19 (54)

Helped me to understand the organisation of rehabilitation services at community level

0 (0)

5 (14)

15 (43)

Deepened my understanding of educational talks

1 (3)

0 (0)

17 (48.5)

Enhanced my ability to conduct outreaches to the community

0 (0)

1 (3)

14 (40)

20 (57)

Helped me to interact with other disciplines in patient care

1 (3)

8 (23)

19 (54)

7 (20)

Improved my public speaking skills

0 (0)

7 (20)

19 (54)

9 (26)

Improved my ability to work as part of a team

0 (0)

2 (6)

13 (37)

20 (57)

Improved my ability to work independently

4 (12)

6 (17)

18 (51)

7 (20)

Improved my skills with regard to conflict resolution

1 (3)

8 (23)

16 (46)

10 (28)

Improved my ability to run meetings

3 (9)

6 (17)

17 (48)

9 (26)

Improved my ability to delegate

3 (9)

3 (8)

16 (46)

13 (37)

Improved my ability to listen to others

0 (0)

1 (3)

12 (34)

22 (63)

Improved my understanding of the roles of other rehabilitation staff

1 (3)

2 (6)

13 (37)

19 (54)

Improved my understanding of how to manage a rehabilitation department

1 (3)

2 (6)

20 (57)

12 (34)

Helped to clarify my values

0 (0)

7 (20)

16 (46)

12 (34)

Helped to improve my personal qualities

1 (3)

2 (6)

19 (54)

13 (37)

Improved my ability to consider the perspectives of others

0 (0)

1 (3)

11 (31)

23 (66)

Deepened my understanding of myself

2 (6)

7 (20)

13 (37)

Learning attribute Community engagement

Professional skills

Personal growth

Overall learning outcome score, %

Total score, mean

CBE = community-based education.

25 20 15 10 5 0

CBE attachment site, district Professional skills

Community engagement

68 67 66 65 64 63 62 61

CBE attachment site, district

Personal growth

Fig. 1. Learning outcome scores by attachment site. (CBE = community-based education.)

Fig. 2. Overall learning outcome scores. (CBE = community-based education.)

Personal growth

The mean overall learning outcome score was 65 (SD 7.0)%. Students placed in district 2 had the highest overall learning outcome score, while those in district 1 had the lowest score (Fig. 2).

All the students reported that the attachment provided an opportunity to gain skills with regard to personal growth. These included clarification of values, personal professional growth, and understanding of self and others.

Learning outcome scores

Students attached to different CBE sites presented with varying scores for community engagement, professional skills and personal growth (Fig. 1). Generally, all the students indicated the most improvement in community engagement skills and the least improvement in their personal skills.

Barriers to effective CBE

The barriers reported by students included unavailability of internet connectivity (82%), unavailability of supervisors during some of the activities (57%), lack of clarity in the objectives given to students (60%) and lack of objectives related to research (74%). Seventeen (48%) participants identified the attachment period as being inadequate to cover all the learning

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Research objectives. All the students in districts 1, 2 and 3 reported a low standard of accommodation at their attachment sites. Limited access to transport to conduct CBE activities and lack of funding for CBE activities were also identified as barriers to effective learning. Failure to communicate using a local language was the only personal barrier to effective learning reported by 13 (37%) participants.

Proposed strategies for promoting learning

Strategies that were proposed to improve the students’ learning outcomes during CBE attachments included revising the objectives (94%), increasing faculty involvement (97%), providing of transport by the university throughout the attachment period (97%), improving the state of the accommodation facilities (60%) and introducing funds directed towards the CBE activities (19%).

Discussion

The development of competence and confidence of students is one of the benefits of CBE experience.[5,8] In our study, the CBE experience offered students an opportunity to improve their skills in community engagement, and develop their professional and personal skills needed to effectively provide rehabilitation services to communities. The CBE attachment enhanced the students’ understanding of clients in need of rehabilitation services. In a hospital setting, students often miss the opportunity to interact with people with disabilities in the commu nity.[8] CBE affords students an opportunity to interact with individuals from different backgrounds and with different abilities.[9] Such interactions enable students to develop in aspects of client centredness and gain a better understanding of the clients’ rehabilitation needs outside the hospital setting.[9] In our study, the participants reported that the CBE attachment had enhanced their future engagement with the community. They also indicated improvements in their professional skills, including interpersonal skills and their ability to work as part of a team. The interaction with the community allows students an opportunity to acquire more knowledge and skills, and attitudes necessary for practice in the community.[6] CBE therefore positively impacts on the students’ understanding of community issues, as it complements classroom learning.[10] The CBE experience equipped the students with skills needed to educate the community on health-related issues, enhanced their ability to conduct outreaches in the community, and improved their public speaking skills. Several authors have reported that CBE offers students a chance to acquire skills in public health services and health promotion.[1-3,5] Such exposure affords students an opportunity to learn about health services within the community. Generally, all students improved in professional skills, including interpersonal skills and their ability to work as part of a team. Interprofessional learning helps students to gain the skills necessary to promote teamwork, communication and collaborative learning.[3,11] Such interactions provide them with opportunities to interact with a multidisciplinary team and, as such, they will have an appreciation of the roles of each of the team members. The students also reported that the attachment had improved their ability to work independently, as well as their skills with regard to conflict resolution. Practice placements, such as CBE, develop students’ self-confidence, thereby facilitating their ability to work independently. Such learning experiences also develop their professional skills, including conflict management.[6,9] From the

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researchers’ personal experience, for students to fulfil the CBE attachment objectives, they have to work together as a team. Conflicts usually arise when tasks have to be shared and they do not agree on how it should be done. Conflict resolution skills will then develop, as students learn to negotiate and agree on how tasks should be shared within the team. Several authors have identified the unavailability of supervisors during some of the CBE activities as a challenge hindering effective learning during attachments.[3,4,6,12] As noted in the current study, despite all occupational therapy and physiotherapy students being attached at district level, there was a variation in overall learning outcome scores based on different attachment sites. This indicates that students had different learning experiences based on the site to which they were attached. Therefore, there is a need to train supervisors and to agree on a model of providing supervision and support services to the students. The introduction of an efficient internet service that facilitates access to e-learning resources may also assist in overcoming the issue of inadequate supervision. To promote effective CBE programmes, e-learning is important, as it permits real-time communication between faculty and students during their attachment, which can help in the daily supervision of students.[4] Unavailability of transport was reported to be a major barrier to effective learning, possibly resulting in clients living in very remote areas not receiving the necessary community rehabilitation services. Additional resources, including transport, are essential in facilitating the effectiveness of CBE programmes.[12,13] Identifying alternative ways of ensuring that transport is available throughout the duration of the placement and introducing funds directed towards CBE, are strategies that can be employed to address transport problems in order to improve students’ learning outcomes. Inadequate time and lack of clear objectives related to research were also reported as barriers to effective learning. The tendency to underestimate the amount of time needed by students for their CBE attachments has been linked to lack of clear objectives in various settings.[3,5,14] Having clear and specific learning objectives enables the students to know exactly what is expected of them;[4,13] therefore, they are able to allocate adequate time for all their CBE activities. Periodically revising the CBE objectives may assist in ensuring that these remain feasible and contextually relevant. Low-standard accommodation was perceived as a barrier to effective learning by the physiotherapy and occupational therapy students who participated in this study. Unavailability of internet access, poor water and electricity supplies, outdated room appliances and poor security are some of the issues that negatively contribute to accommodation standards.[3,4] Currently, the maintenance for most of the hostels used by students during the CBE attachment is the responsibility of the hospitals where these hostels are built. With the prevailing economic hardships in Zimbabwe and the recent freezing of posts by the Ministry of Health and Child Care, most hospitals have shortages of cleaning staff. Cleaning of the students’ accommodation may not even be on the list of cleaning priorities for the hospitals.

Study limitations

This study was conducted to determine the learning outcomes of rehabilitation students at the University of Zimbabwe and to identify factors affecting learning during the CBE attachments. It would have been ideal to establish the consistency of the study instrument before conducting the research. However, the data collection instrument did not undergo reliability testing, and the authors acknowledge this omission as a limitation of the study.

Research Conclusion

Experiential learning during the CBE attachment for occupational therapy and physiotherapy students offered them an opportunity to apply theoretical knowledge to practise and develop personal, professional and community engagement skills. However, barriers, including lack of clear research-related objectives, limited resources for CBE activities, inadequate supervision and limited exposure to communities in terms of time allocated for the attachment, negatively affected the learning experiences. The availability of more resources for CBE activities may improve the overall learning experiences of students. Acknowledgements. Our most sincere gratitude is extended to lecturers at the Department of Rehabilitation, College of Health Sciences, University of Zimbabwe, for their assistance and guidance throughout the research project; the Joint Research Ethics Committee of the College of Health Sciences; the Medical Research Council of Zimbabwe for reviewing the study protocol; the dean of the College of Health Sciences for granting permission to carry out this study; to the physiotherapy and occupational therapy students at the University of Zimbabwe, who participated in the study; and to the physiotherapists and occupational therapists who participated in the pilot study. Author contributions. TN: developed the research protocol, collected and analysed the data, and contributed to writing the manuscript; TMC: developed the research protocol, collected and analysed the data, and contributed to writing the manuscript; NM: analysed the data and contributed to writing the manuscript. Funding. None. Conflicts of interest. None.

1. Dreyer A, Couper I, Bailey R, Talib Z, Ross H, Sagay A. Identifying approaches and tools for evaluating community-based medical education programmes in Africa. Afr J Health Professions Educ 2015;7(1):134-139. https://doi.org/10.7196/AJHPE.568 2. Bailey RJ, Baingana RK, Couper ID, et al. Evaluating community-based medical education programmes in Africa: A workshop report. Afr J Health Professions Educ 2015;7(1 Suppl 1):140-144. https://doi.org/10.7196/ AJHPE.475 3. Kaye D, Mwanika A, Burnham G, et al. The organization and implementation of community-based education programs for health worker training institutions in Uganda. BMC Int Health Hum 2011;11(1):1. https://doi. org/10.1186/1472-698X-11-S1-S4 4. 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 5. Kaye DK, Muhwezi WW, Kasozi AN, et al. Lessons learnt from comprehensive evaluation of community-based education in Uganda: A proposal for an ideal model community-based education for health professional training institutions. BMC Med 2011;11(1):1. https://doi.org/10.1186/1472-6920-11-7 6. Wald HS, Davis SW, Reis SP, Monroe AD, Borkan JM. Reflecting on reflections: Enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med 2009;84(7):830-837. https:// doi.org/10.1097/ACM.0b013e3181a8592f 7. Lichtenstein G, Tombari M, Thorme T, Cutforth N. Development of a national survey to assess student learning outcomes of community-based research. J High Educ Outreach Engage 2011;15(2):7-34. 8. Shields N, Taylor NF. Physiotherapy students’ self-reported assessment of professional behaviours and skills while working with young people with disability. Disabil Rehabil 2014;36(21):1834-1839. https://doi.org/10.3109/096 38288.2013.871355 9. Yorio PL, Ye F. A meta-analysis on the effects of service-learning on the social, personal, and cognitive outcomes of learning. Acad Manag Learn Educ 2012;11(1):9-27. https://doi.org/10.5465/amle.2010.0072 10. Davies K, Harrison K, Clouder D, Gilchrist M, McFarland L, Earland J. Making the transition from physiotherapy student to interprofessional team member. Physiotherapy 2011;97(2):139-144. https://doi. org/10.1016/j.physio.2010.08.00 11. Rodger S, Fitzgerald C, Davila W, Millar F, Allison H. What makes a quality occupational therapy practice placement? Students’ and practice educators’ perspectives. Aust Occup Ther J 2011;58(3):195-202. https://doi. org/10.1111/j.1440-1630.2010.00903.x 12. Burggraaf A, Bourke-Taylor H. Occupational therapy students’ fieldwork placement: Institutional and community based rehabilitation models in the Solomon Islands. N Z Occup Ther J 2008;55(2):25. 13. Okayama M, Kajii E. Does community-based education increase students’ motivation to practice community health care? A cross sectional study. BMC Med 2011;11(1):1. https://doi.org/10.1186/1472-6920-11-19 14. Kristina TN, Majoor GD, van der Vleuten CP. Defining generic objectives for community‐based education in undergraduate medical programmes. Med Educ 2004;38(5):510-521. https://doi.org/10.1046/j.1365-2929.2004.01819.x

Accepted 23 May 2017.

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Research

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

Experiences of South African student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery L M Modiba, D Cur Department of Health Studies, College of Health Sciences, University of South Africa, Pretoria, South Africa Corresponding author: L M Modiba (modiblm@unisa.ac.za)

Background. In the department of nursing at the University of the Witwatersrand, South Africa, one of the requirements for students to complete their Bachelor of Nursing Science degree is to choose a pregnant woman and follow up on her care, through pregnancy, during birth and up to 6 weeks after delivery. Objective. To explore and describe student midwives’ experiences in the follow-up of a woman through pregnancy, birth, postpartum and until 6 weeks after delivery. Methods. The research design was qualitative, descriptive, exploratory and contextual. Purposive sampling was used, and 21 student midwives consented to be part of the study. Semi-structured face-to-face interviews were conducted with the student midwives after they completed the follow-up project. These interviews were tape-recorded and transcribed verbatim by an independent transcribing service. Results. The findings in relation to the research question were synthesised under three themes: building relationships with the women; challenges associated with the follow-up experience; and positive aspects of this experience. Conclusion. The follow-up experience provided midwifery students with unique and important learning opportunities that they would not have experienced in standard or hospital-based clinical placements alone. Afr J Health Professions Educ 2017;9(4):194-198. DOI:10.7196/AJHPE.2017.v9i4.730

Childbirth is a unique and special experience for every woman. Unfortunately, however, some would argue that it is increasingly becoming a ‘medicalised’ experience, in which women lose their rights and their control over their own bodies. Studies such as that of Spurgeon et al.[1] have found that this medicalisation leaves women feeling helpless, and with no freedom of choice. The medicalisation of women’s bodies has led to widespread perceptions of childbirth as a specialist field in which only doctors have appropriate knowledge. However, it can be argued that the care that can be provided by midwives around the time of childbirth can contribute to a good start for the baby and parents during this critical period of human life. As Fraser and Cooper[2] highlight, a midwife meets a woman at the beginning of her pregnancy and provides care throughout it. If the woman has a low-risk pregnancy, the midwife works with the medical team, but (s)he is still responsible for all the midwifery care. In South Africa (SA), the midwife carries out his/her functions based on the scope of practice of a midwife,[3] keeping in mind the code of conduct and making ethical decisions regarding the care of mother and child. All midwives must realise that they are able to make independent judgments regarding the care of a patient according to their knowledge, qualification and skills. The follow-up experience is an innovation on the part of the University of the Witwatersrand (Wits) in Gauteng Province, SA. The experience provides the student midwives with the opportunity to form extended relationships with the women who they have been with during pregnancy, labour and birth, and 6 weeks after delivery. This project had been in place for 7 years prior to the time of this study. The nursing department and all institutions in which student midwives are placed for clinical education, e.g. community-service clinics, are aware of the follow-up

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programme, and work with students to assist and enable them to undertake the follow-up experience. All 21 student midwives who were enrolled for midwifery in the years 2009 and 2010 were given guidelines specified by the nursing department, according to which a student must: • choose one pregnant woman in her first trimester of pregnancy, and give her support throughout pregnancy, birth and postpartum until 6 weeks after delivery – i.e. (s)he will be on call throughout the woman’s journey • choose a woman perceived to be in the ‘low-risk’ category, to allow them good exposure without involving obstetricians • keep records of all their contact hours, as these would be added to their training hours as required by the SA Nursing Council regulation (R425) • keep anecdotal notes, e.g. pictures • keep journals • write narratives as (s)he continues to support the woman • exchange contact details with the woman, for communication • when visiting the woman at home, be accompanied by one of their colleagues, as some areas are dangerous to visit • by the completion of the project, have written down this experience, and must submit it for marking by the lecturer. The process of recruiting the women varied, sometimes being undertaken at the antenatal clinic of a public hospital, or at a church, or via family and friends. The follow-up experience has the potential to contribute quite significantly to the midwifery practice of students, as the time spent in these experiences is additional to their standard clinical placement.

Research Problem statement

I have observed that student midwives in SA believe that their prior learning in nursing education causes them to focus on task performance rather than on interaction and on offering support during midwifery training. As a new learning activity, there is no current research that indicates whether any learning actually arises from this experience, and if there is any learning, what is learnt and how this learning occurs. Little has been written about the experiences of offering continuous support during pregnancy in the SA setting. The current evaluations of the follow-up experience in the literature (Brook and Barnes[5] and Davis and McIntosh[6]) do not explore whether learning occurs as a result of this experience. From this problem, the following questions arose: • What are the personal experiences of student midwives on the follow-up of a pregnant woman from pregnancy until 6 weeks after delivery? • What are the learning experiences of student midwives when caring for a pregnant woman from pregnancy until 6 weeks after delivery? • What are the challenges associated with this follow-up experience?

that their names would not be given to any other person. Ethical clearance (ref. no. M10342) was received from the Wits Human Research Ethics Committee. The students were aged between 21 and 26 years old, and only four had had personal experience of childbearing. At the antenatal clinic of the public hospital, the pregnant women were informed by the qualified midwives about the need for student midwives to gain follow-up experience of pregnant women; therefore, when the student midwives came to recruit them, they were already aware of the programme. The student midwives chose women they were comfortable with, according to either language or culture. On orientation in class, students were also informed that they could choose to follow up a family member, friend or fellow congregant, as long as they received the individual’s permission.

Data collection

The purpose of this research was to determine the student midwives’ personal learning experiences in the follow-up of a pregnant woman until 6 weeks after delivery. To achieve the purpose, the following objectives were set: • to explore and describe student midwives’ personal experiences in the follow-up of a pregnant woman until 6 weeks after delivery • to identify and describe learning experiences associated with the followup experience • to identify and describe the challenges associated with the follow-up experience.

Semi-structured face-to-face interviews were conducted with the student midwives after completing this project. In order to manage the issue of potential intimidation, as I was their lecturer, I asked a midwifery colleague who also has experience with qualitative interviews to conduct the interviews. I then provided the interviewer with an overview of the research and the interview questions, and introduced her to the students after informing them that they would be interviewed. These interviews were tape-recorded and transcribed verbatim by an independent transcribing service. Student midwives were asked to keep journals and to write narratives throughout the experience, which also formed part of the data collected. The purpose was to assist the student midwives to reflect on and evaluate their experiences in offering continuous support. The students were asked to describe their experiences of the followup of the pregnant women.

Methodology

Data analysis

Purpose

A qualitative, exploratory, descriptive and contextual phenomenological study was undertaken to examine student midwives’ learning experiences of a follow-up of pregnant women to 6 weeks after delivery. Burns and Grove[7] have defined qualitative study design as taking a systematic, subjective approach in describing life experiences (in this study, the experiences of the student midwives) and giving them meaning. Descriptive and explorative methods are used interchangeably to gain information and to provide a picture of a situation as it naturally occurs, while contextual aspects are vital in considering the setting of the study, e.g. hospital or home.[8] This study was conducted within Witsand in a public hospital, the Charlotte Maxeke Johannesburg Academic Hospital, in Gauteng Province, SA, over a period of 2 years (2009 - 2010). Annually, the labour ward takes in about 5 000 women, who may either have uncomplicated deliveries or experience complications. In this ward, 10 student midwives from other nursing/midwifery colleges and from the university receive their clinical training. Ten qualified midwives, five doctors and six staff nurses work in this labour ward. A total of 21 student midwives were enrolled in the midwifery programme for 2 years. In the first year, they dealt with ‘normal’ midwifery, and in the second year, ‘abnormal’. Through purposive sampling, all students who were registered for midwifery volunteered to participate in this study, and signed informed consent forms in which its purpose and objectives were clearly explained. They were informed about their right to withdraw their participation at any time. Confidentiality and anonymity were maintained by not using their real names, and they were guaranteed

A qualitative content analysis was used to allow me to interpret the underlying meanings of the texts, as suggested in the literature by Graneheim and Lundman.[9] As I was also these students’ lecturer, and involved in marking their portfolios, the experiences and narratives documented were read, and meaningful units were identified. These units consisted of text from a few words up to several sentences, the meanings of which were interpreted. During the interpretation, subthemes were identified, and a main theme emerged at the end of this process. The findings in relation to the research questions can be synthesised under three themes: personal experiences associated with follow-up; learning experiences associated with follow-up; and challenges associated with the follow-up experience. The results of the analysis are presented below under these headings.

Personal experiences associated with follow-up

Under this theme, three subthemes emerged: ‘getting to know what makes the woman tick’; ‘the woman’s care is in your hands’; and feeling under a lot of pressure. ‘Getting to know what makes the woman tick’ Students perceived the follow-up experience to be focused on the woman, rather than anything else. Getting to know the woman was more than a simple social activity. It involved a deeper relationship that led to the

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Research midwifery student learning about the woman’s wider environment and personal circumstances. One participant explained: ‘You really get to know, especially with home visits, what her home environment is like and how that’s impacting on the person that she is and the choices that she is going to make.’ This theme shows the student becoming deeply involved in the follow-up experience and learning from it. This relationship is built on important facets such as the relationship with her family or partner, demonstrating that this is more than a simple social interaction. ‘The woman’s care is in your hands’ The theme involves the student learning from engaging with the woman and feeling that this puts the woman’s care in their hands. This was described by one student as follows: ‘You actually get to speak to a real person rather than just reading books or just practising on dolls. It is a lot different in the real world than sitting and reading a textbook. You learn that not every labour is like a textbook labour.’ Feeling under a lot of pressure Students felt under a lot of pressure because of the overload of work from other subjects, e.g. community-health nursing sciences, while they could also be interrupted by their follow-up woman at any time. This was articulated as follows: ‘I will be sleeping and when a phone rang would say dear God, I hope this is not my follow-up woman. I had a young child and still married, and if called at that time it is really a difficult time. It was gruelling!’ In summarising this theme, most of the participants felt that this experience exposed them to getting to know the woman better, so that the care they were providing was centred on trust. The experience clearly identified interaction where a significant relationship was built. Some participants articulated the difficulties they were exposed to when they were having family problems.

Learning associated with experiences

Under this theme, three subthemes also emerged: ‘being there in the moment’; relationship-building with the woman; and the uniqueness of each woman’s journey. ‘Being there in the moment’ This illustrates how learning took place, and it was described by one participant as: ‘What I have learned through this experience is more than what I have learned in class.’ Another participant said ‘It has been a deep learning experience because one gets to see the transformation that pregnancy, birth and motherhood brings and what impacts on this. Not just fragments of this from the textbooks, it has taught me about taking personal responsibility as a midwife.’ Relationship-building with the woman Student midwives in this study stressed that the relationships they formed with these women during this time were important for a number of reasons – they knew about the woman, her wishes, her past experiences and her personal circumstances, and they came to understand what impact these had on her experience of pregnancy, labour and early parenting. These relationships meant that the students were able to provide care that was personal and tailored for that particular woman. They described how they

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came to realise that being able to get to know the woman was a valuable opportunity: one student midwife said ‘It has given me a “bigger picture” approach – holistic care as well as teaching me that my beliefs really have little relevance and it comes about to the woman’s own choices that matters.’ The experience provided student midwives with an opportunity to form extended relationships with the women. Being present Students reported that the women did not want to be left alone during labour. The presence of the student helped the women to relax and feel more secure. The student’s presence was expressed by touch or talking, as one participant described: ‘The woman wanted me to hold my hand on her belly at every contraction. At first I found it odd. I wondered how it could help her, but then I saw that it really did. To her it was probably important to feel that I was actually there. It seemed it made her to relax.’ Another said: ‘I learned that one sometimes does not have to do so much for the woman, it can be enough just to be there for her and to listen.’ According to Hunter,[10] ‘presence’ involves a willing interaction between the midwife and the woman, which requires trust on the part of the woman, and the giving of self (engagement, attentiveness, time and awareness of the encounter) by the midwife. This has also been recognised by Kennedy et al.,[11] who consider the art of midwifery as being present without interfering; as long as the process is working as it should, midwifery is the art of ‘doing “nothing” well’. Feeling of trust Student midwives also felt that the women trusted them because they knew them, and that this trust was significant for the women. They recognised the value of having an existing relationship prior to labour and birth, as identified by participants: ‘There’s a better trust there, and it feels a bit more like almost a friendship or a partnership with the woman.’ ‘It is so much easier and rewarding to care for women in a continuity of care. The birth experience in particular becomes so less scary for women when they feel well supported by a known and trusted person.’ The uniqueness of each woman’s journey Some participants described how they learnt about how women experience their journey. One participant said: ‘I have learned that pregnancy and birth is a different experience for all women and one should not make any assumptions about how women experience it.’ Another one explained: ‘They have all been different so far and each and every one had something special. The issues that came up woke my curiosity and got me reading more.’ In summarising this theme, student midwives recognised that the development of a relationship and a commitment to the woman allowed them to provide her with the type of care that they knew was appropriate for her, particularly during her labour and birth. Midwifery literature (Kirkham[4] and Hunter[12]) has previously shown that midwives experience work differently when they are able to build relationships with women. According to Fraser et al.,[13] it is through the development of relationships between caregivers and childbearing women and their families that we make the change from ‘faceless institution’ to ‘humanistic supportive care’.

Challenges associated with the follow-up experience

While student midwives spoke of their experiences of being able to develop relationships with women, they also articulated aspects of the follow-

Research up experience that were difficult: recruiting; poor support; conflicting priorities; finances; and intimidation. Recruiting The student midwives described the recruitment of a woman for follow-up as a difficult and challenging experience, and it was explained as awkward and sometimes time-consuming, as indicated in the following statements: ‘I was frustrated because she couldn’t understand me well. I spoke too quickly for her but I corrected myself and the communication between us grew. My first feeling was that she would be just another attempt, soon she would not come for the visits any longer and I would be sitting in looking for a new woman.’ ‘At the start of the project I wanted to quit because of fear of rejection, but because time was running out I had to do it. It is also a very confronting experience to have to ask a woman if you can be a part of this very intimate time of her life.’ In summarising this theme, it was clear that there were difficulties associated with recruiting women, e.g. it was awkward, and it sometimes took a long time as the participants were also supposed to study and manage work and family life. Poor support Student midwives received some support from the university, midwives, doctors and their colleagues, but it was not always sufficient, and this was reaffirmed by a student midwife who described how midwives did not ring her for the labour and birth: ‘My follow-up woman asked the midwife to call me as soon as she was admitted but the midwife did not do it. So, I missed out on being at the birth.’ Another student explained: ‘After my follow-up woman lost her child, I walked to an empty room and I sat alone and cried. I was interrupted when a nursing sister walked in the room and began shouting at me, saying that is her room, at least she stopped when she saw my puffy eyes, and she asked me and I told her that I was crying because my baby died to which she replied ‘Oh!’ And she continued to read her newspaper. I asked myself where her compassion was!’ This showed poor professional support from qualified midwives. One participant explained that sometimes one develops an emotional attachment and this becomes difficult: ‘You can never predict how a birth will end up, I also found the woman to be more trusting and confident in labour. I actually preferred not to know them well as it interfered with my clinical judgement. I was too emotionally involved.’ Conflicting priorities One concern was about the difficulties associated with trying to balance university requirements with the follow-up experience. This was revealed in the following comment: ‘I had to miss the appointment with my follow-up woman as I was on the train for community clinical placement in another province.’ This illustrates that although this project was supported by the university, there were clashes as students were also registered for other courses than midwifery, e.g. psychiatry and community-health nursing. Finances Although the university recognises the follow-up project, difficulties were encountered when student midwives needed to spend money on things such as purchasing cellphone credit in order to call their follow-up woman, and paying for transport when visiting the woman at home. This was illustrated by the following statement: ‘I had to purchase phone credit in order to

communicate with the woman. And when I went to visit her at home I bought fruits for her other kids and at the same time had to pay transport money.’ In summary, the student midwives explained that although students are required to commit time, other resources are also needed, such as travel expenses to visit the women at home. Intimidation Students had to follow up some of the women at home in order to get to know them as members of their families, and to understand the environment in which they were living. The general experience was found to be intimidating, especially if the woman was not at home. This was described by one participant: ‘When I arrived there I found the partner who welcomed me and as I was asking as to where Ms X was, he mentioned that she is gone to the homestead, but surprisingly he start to flirt with me and I had to go out of that place running.’ The student midwives, in summary, mentioned that it was not always safe to travel alone, as sometimes they would be faced with awkward situations at the homes of the women, or risked being robbed.

Discussion

The research showed that the implementation of a follow-up woman programme has many benefits to both student midwives and women during their pregnancy, delivery and postnatal period. If care is appropriately organised, and midwives gain interpersonal and clinical skills and knowledge, it is more likely to be successful. The way care is organised, including the pattern and culture of practice, is probably one of the most important factors in creating effective, sensitive and individual care.[13] It is important that midwives ensure continuity of care to mothers and babies throughout pregnancy, the birth experience and the puerperium. ‘Continuity of care’ refers to the follow-up of a woman to ensure that her needs – both physical and psychological – are met in each consultation, and that the same midwife continues to care for her throughout the period from early pregnancy to after birth. In this way, in any given encounter with the maternity services, a woman can feel confident that her caregiver will know what has gone before, so that she will not have to repeat her story yet again. Equally, decisions about her care will have been made as a result of policies that are shared by all her caregivers and to which all are willing to adhere, so that she will not be given conflicting advice. This is further articulated by Homer et al.,[14] who argue that continuity of the carer refers to care by a midwife whom the woman has met previously and feels that she knows. A lot is gained through continuity of care, such as the trust and co-operation of the patient in solving issues at any time in pregnancy and labour. This is supported by Pairman,[14] who refers to the woman-student relationship, and the learning that the student gains from this experience, as powerful. It also increases the quality of care of the woman in the sense that the midwife has the opportunity to understand her background and culture, to get to know her more deeply and to allow the establishment of a relationship between them. When in labour, the woman will have support from someone whom she already knows and has a trusting relationship with. This is confirmed by Fraser et al.:[13] women identified good communication skills to be of primary importance, although some women also wanted more than this and expected midwives to have a special relationship with them. The pregnant woman may also come to

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Research feel comfortable enough to question the midwife and to participate in any decision-making. Each labour is a unique experience, and greater experience with diverse labours means midwives will experience fewer caesarean-section cases and more successful second stages of labour, in terms of a shorter second stage and intact perineum.[16] Midwifery offers the possibility of making the childbirth experience of a woman special and unique, and the experience can also end up being just as unique to the midwife, because with each woman, the midwife is able to create a different and personal bond. As midwives, we can empower women and make a difference for them, at the same time creating a learning opportunity for ourselves.[17]

Conclusions

The follow-up experience provided a significant learning environment for midwifery students. Students identified the learning they received from the experience as uniquely individual. They articulated that they learned through interaction with each woman, and their ability to be hands-on with her. The follow-up experience provided midwifery students with unique and important learning opportunities that they would not experience in standard or hospital-based clinical placements alone. These learning experiences occur primarily because students are paired with individual women. It is this relationship that provides serendipitous learning, in which learning is informal, the knowledge gained is high and motivation remains with the learner. Students are likely to learn more from these experiences if they are embedded within courses, where support is provided for reflection, and where they are not forced to take a superficial approach to care as a result of an excessive workload.

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Acknowledgements. I would like to thank the students who agreed to participate in this study. Author contributions. Sole author. Funding. None Conflicts of interest. None 1. Spurgeon P, Hicks C, Barwell F. Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot Changing Childbirth schemes compared with a traditional model of care. Midwifery 2001;17(2):123-132. https://doi.org/10.1054/midw.2001.0255 2. Fraser MD, Cooper IS. Myles Textbook for Midwives, 14th ed. New York: Churchill Livingstone, 2003. 3. South African Nursing Council. Scope of Practice of a Registered Midwife. No: R2488. Pretoria: SANC, 1990. 4. Kirkham M. The Midwife-Mother Relationship. Basingstoke: Macmillan, 2000. 5. Brooks C, Barnes M. Experience-based educational strategies to promote woman-cantered midwifery practice. Aust J Midwifery 2001;14(1):22-26. https://doi.org/10.1016/s1445-4386(01)80031-8 6. Davis D, McIntosh C. Partnership in education: The involvement of service users in one midwifery program in New Zealand. Nurs Educ Pract 2005;5,274-280. https://doi.org/10.1016/j.nepr.2005.02.002 7. Burns N, Grove SK. The Practice of Nursing Research: Conduct, Critique and Utilization, 5th ed. St Louis: Elsevier/Saunders, 2007. 8. Lobiondo-Wood G. Nursing Research Methods: Clinical Appraisal for Evidenced-Based Practice, 6th ed. St Louis: Mosby, 2006. 9. Graneheim UP, Lundman E. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today 2004;24(2):105-112. https://doi.org/10.1016/j.nedt.2003.10.001 10. Hunter B. The importance of reciprocity in relationships between community-based midwives and mothers. Midwifery 2006;22(4):308-328. https://doi.org/10.1016/j.midw.2005.11.002 11. Kennedy H, Shannon U, Chuahorm U, Kravetz M. The landscape of caring for women: A narrative study of midwifery practice. J Midwifery Womens Health 2004;49(1):14-23. https://doi.org/10.1111/j.1542-2011.2004. tb04403.x 12. Hunter LP. Being with woman: A guiding concept for the care of labouring women. J Obstetric Gynecol Neonatal Nurs 2002;31(6):650-657. https://doi.org/10.1177/088421702129005281 13. Fraser MD, Cooper AM, Nolte AGW. Myles Textbook for Midwives, African Edition. Edinburgh: Churchill Livingstone, 2006. 14. Homer CS, Davis GK, Cooke M, Barclay L. Womenâ&#x20AC;&#x2122;s experiences of continuity of midwifery care in a randomised controlled trial in Australia. Midwifery 2002;18(2):102-112. https://doi.org/10.1054/midw.2002.0298 15. Pairman S, Massey S. Where do all the midwives go? A report on the practice choices made by Bachelor of Midwifery graduates. N Z Coll Midwives J 2001;25:16-22. 16. Halldorsdottir S, Karlsdottir SI. Journeying through labour and delivery: Perceptions of women who have given birth. Midwifery 1996;12(2):48-61. https://doi.org/10.1016/s0266-6138(96)90002-9 17. Lavender T, Walkinshaw SA, Walton I. A prospective study of womenâ&#x20AC;&#x2122;s views of factors contributing to a positive birth experience. Midwifery 1999;15(1):40-46. https://doi.org/10.1016/s0266-6138(99)90036-0

Accepted 27 March 2017.

Research

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

Self-leadership traits of academics to conform to a changing highereducation environment K Jooste,1 PhD; J Frantz,2 PhD 1

Department of Nursing Science, Faculty of Health and Wellness, Cape Peninsula University of Technology, Cape Town, South Africa

Department of Physiotherapy, Faculty of Community Health, University of the Western Cape, Cape Town, South Africa

Corresponding author: J Frantz (jfrantz@uwc.ac.za)

Background. Now, perhaps more than ever, leadership is seen to be associated with those who manage to create and promote a compelling and meaningful sense of their own values and identity that is demonstrated in the traits they portray to followers. In higher-education sectors, ‘leadership at all levels’ refers to both those in formal roles, such as departmental chairpersons, and those in informal roles, such as postgraduate-degree supervisors or mentors. Objectives. To explore academics’ experiences of their self-leadership traits in a higher-education institution in a changing educational environment. Methods. A qualitative, exploratory, descriptive and contextual research design was followed. The study population consisted of senior academics in departments in the Faculty of Community and Health Sciences at a residential university in South Africa. Purposive convenience sampling was used to include 10 available participants, all vice deans or heads of department, after which data saturation occurred. Individual interviews were conducted that lasted around approximately 45 minutes. The data were analysed using open coding. Results. Five themes emerged around leadership: its development over time; that it can be earned though different means; that it is influenced through personal experience; the role of role models; and environmental encouragement. Conclusion. The study findings indicated different views on the development of leadership skills. Participants commented on the importance of a complex blend of competencies needed by leaders. A number of suggestions were put forth on how to develop leadership skills. Afr J Health Professions Educ 2017;9(4):199-202. DOI:10.7196/AJHPE.2017.v9i4.823

Leaders in higher education are required to address the imperatives for change that come from extrinsic sources, as well as from intrinsic pressure that results from the growth of knowledge itself. Academics need to have the confidence to exert their power and be at the forefront of leading other people towards the actualisation of the objectives of a team.[1] In the highereducation sector, visible leadership is usually expected both from people in formal roles, such as heads of school, departmental chairpersons or deans, and those in informal roles, such as postgraduate-degree supervisors who are beginning to master self-leadership. Persons engaging in self-leadership frequently cultivate a sense of ownership in terms of their tasks and work processes. As a result, self-leading individuals may demonstrate higher levels of commitment to their tasks, goals, teams, or organisations than individuals who do not engage in self-leadership.[1] In order to understand self-leadership, one needs to have insight into how one is classified as a leader in higher education, whether the role is formal or informal, whether the leader exerts an intentional influence or is it determined by context, and how leadership is embodied in individuals.[2] One must first be able to lead oneself before leading others. Perceptions of who leads, and why they lead, are as important as what they do and how and where they do it. Now, perhaps more than ever, leadership is seen to be associated with those who manage to create and promote a compelling and meaningful sense of their own values and identity. This is nothing unique to higher education, but the way in which it must be accomplished is highly context-specific.[3] Self-leadership of academics fundamentally refers to being driven by motivation and self-influence to direct oneself towards achieving

optimum performance in a situation.[1] Leadership should be from within, and can thus be defined as ‘authentic self-expression that creates value’.[4] This form of leadership can thus be identified at all levels of an organisation. Leadership cannot be removed from the culture of an organisation. The philosophy of the Faculty of Community and Health Sciences at a higher-education institution in South Africa (SA) focuses on developing leaders at all levels who are able to adapt, collaborate and work within diversity, and who can lead themselves. As it had not been previously studied, it was unclear how academics experienced their selfleadership in their day-to-day challenges as senior academics. Thus the aim of this study was to explore experiences of academics in a highereducation institution of their self-leadership traits in an educational environment. The study was conducted within Cashman’s[4] theoretical framework of seven pathways for an academic, as it was considered relevant to the specific concept of self-leadership and to the context of academics in this study, focusing on leading from the inside out.

Methods

Study design

This study used a qualitative, exploratory, descriptive and contextual research design. This design provided insight into the experiences of academic self-leaders in a changing higher-education environment, obtaining rich data and an in-depth understanding of the phenomenon, namely self-leadership.

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Research Setting and study population

The study population consisted of all senior academic leaders in the Faculty of Community and Health Sciences at a residential university, in the disciplines of physiotherapy, occupational therapy, dietetics, psychology, social work, sport, recreation and exercise science, natural medicine, nursing and public health. Purposive convenience sampling was used, and 10 participants, occupying the roles of deans, heads of department (HODs) and directors of schools and academic units, were selected until data saturation occurred, when no new data emerged.

Data collection

Individual semi-structured interviews were conducted that lasted approximately 45 minutes. The interviews were tape-recorded and held in a private room.

Data analysis

The data were analysed through open coding, to identify themes and categories. The authors and independent coder reached consensus on the themes that emerged from the data.

Ethical considerations

This study received ethics clearance (ref. no. 23/4/2015) from the Senate Research and Ethics Committee at a university in the Western Cape, SA. All participants signed a written consent form after receiving information on the purpose of the study. They could withdraw from the study at any stage. The interviews conducted were confidential, and names did not appear on the transcripts.

Results

Seven themes emerged that corresponded to the self-leadership skills outlined by Cashman:[4]

Developing awareness and mindfulness of character and personality (personal mastery) Self-awareness can be described as adopting a strong orientation toward achievement, holding high expectations for yourself and others and pushing yourself and others to achieve at high levels.[5] One participant mentioned that he focused on discovering himself while being mindful of his abilities: ‘We can be aware of what is a leader, a leader should do, should do this, and this, and this, you should manage, you should do this, you should manage time, you should […] but I think leadership is also discovering of yourself, and your abilities.’ Another participant was aware of his inner self (inner consciousness), which he said contributed to his leading of others: ‘So I think a lot of my drive and a lot of my work starts with my inner work and I do believe that things work from the inside out, and if I’m on top of my game my inner world then the outer world follows, then I’m able to provide the leadership, then I’m able to be the role model.’ One of the participants also mentioned that leadership characteristics should be developed within a person, and that this development takes time: ‘So I think there are certain skills that, or values that [are] inbred in the person that makes them a leader, but there are also certain skills that need to be developed within a person.’

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Another participant indicated that the changes in personality and characteristics of a developing leader were bound by the environment or context: ‘That people can learn those skills and that quite often what emerges as leadership qualities is dependent on the environment in the context in which the individual finds themselves.’

The importance of actions having a purpose (purpose mastery) Purpose mastery acknowledges creating a vision and figuring out where the organisation is heading, and getting people moving in that direction.[5] An HOD mentioned having a vision, with a clear plan of the actions that were needed to move forward: ‘On the one hand, is that the person should have a vision. He should know where he takes the people to, and then of course you should have an idea how to get there […] The vision is to make this department the best department […] but should be realistic […] you should have a clear path on how you can get there, and all the things you should put in place to get there.’ Another participant mentioned setting clear goals (purpose) through mentorship and coaching: ‘So I think that mentorship and coaching is very important. I think that peer networks, sharing, getting people doing similar things. Setting goals, goal setting, you know.’

From problem focus to opportunity (change mastery)

Effective leaders should not lose sight of their long-term vision in the midst of change.[4] One participant realised that in the past there were limitations in the higher-education sector, and mentioned that changing oneself to act as a leader was better for the future: ‘I think everybody is protecting their own territory […] It comes from the past where they needed to do that and if we are able to move outside of our silos and move into, if everybody realises that they are a leader and they are promoting, for example, the faculty […] then we would start moving better.’ Also, being aware of change, and able to adapt, is needed on different levels, and it was mentioned that: ‘You need to be in touch with what is going on, the changes. Things are rapidly changing, so you need to be aware of what’s going on in education and in health, and politically, on education, on a whole lot of levels.’

Recognising that there are contributing factors that make leaders successful (interpersonal mastery) Another contributing factor in becoming a successful leader is interpersonal mastery, where people learn from each other.[4] A need was identified for interpersonal sharing of ideas through peer support: ‘I think peer support is a very important thing, because I think at the moment you come into the position, and you have to deliver, but there’s actually not a place where you can really go and create ideas and things like that’. A participant stated that a two-way relationship is essential: ‘I think also being in leadership the relationships are always bidirectional, it can never just come from one side’.

Research Taking your own journey into being (being mastery)

Self-leaders should take time to realise who they are, by reflecting on their life experience, where they have been and where they might go.[4] One participant was of the opinion that to achieve more as a leader, one first needs to understand oneself and one’s own potential as an individual: ‘Myself, I think it started off with me and engaging in processes with myself to get to a point where I could understand myself. I don’t think one could be an effective leader if you haven’t done the work on yourself. It’s like I always start my courses and say research and know thyself. Because one can never go out and know something or somebody else if you don’t know yourself, so I think a lot of my drive comes from that.’ It was also mentioned that self-confidence was needed: ‘I think part of leadership is about confidence within yourself and if you … if you are solidly grounded within yourself and you confident in terms of who you are and it doesn’t require somebody with a big voice.’

Making choices wisely, to be effective (balance mastery)

Mastering balance refers to recognising that every choice we make potentially also affects our work balance to survive.[4] One participant highlighted her own role in empowerment and choices in self-development: ‘I know that my opinion is that I will go ahead and empower and build my knowledge and get the books and everything, my growth is in my hands. So I’m going to do it irrespectively whether someone else does it or not.’ Another participant mentioned his own role in taking wise and accountable decisions and actions: ‘They should be able to take up initiatives, if nothing is happening, say at a certain level as the job’s got to be done. We can’t all wait for something to happen, we’ve got to actually, sometimes say, this is the situation, I’m accountable to staff and students and everything; if no one else is guiding me, I go out and find it.’ The importance of sharing experiences with other people also came to the fore: ‘As leaders we are not prepared for all circumstances in life but if we are given an opportunity to share and in a safe space, then I feel that people will grow, because I find that I learn a lot from sharing, talking to others.’

Taking actions connected to purpose and vision (action mastery) Our inner resources and values shape our actions and behaviour in the world. Personal values shape decisions and behaviour, and are drivers in creating organisational values.[6] The process of drawing others into a common vision was outlined: ‘What comes to mind is vision […] It’s around knowing long-term where your department is heading, and how it should get there. And then, to facilitate a group of people to buy into that vision, share that vision, and be moving towards that vision.’ One participant expressed how her experiences in life had developed her as a leader: ‘I think you […] leadership skills one develops, your personal experiences in life is definitely one of the things that contribute to the development of leadership skills. Your values, and your beliefs in life also contributes to the type of leadership and then the opportunities that you have had, to be in a leadership role.’

Discussion

Personal mastery is considered to be achieved when one comes to see life from a new perspective, while following the principles of having purpose, vision, belief and commitment, and knowing oneself.[7] It seemed that through self-awareness, the participants sought new ways of doing things and shaping their environment, while encouraging their followers to be a part of the changing process. Under the mentorship model, a more experienced person provides advice and serves as a partner in developing the mentee’s skills, so as to become more self-aware in situations in which leadership should be shown, and also as part of developing him/her for future leadership succession. The participants highlighted the importance of having a vision or purpose for the future. Leadership was shown in that participants indicated that they moved from problems to opportunities, that their workplace was always changing and they needed to accept this, and that they needed to adapt to change. Participants understood that to create change, it is important to have a clear vision of the future within an organisation that benefits the community it serves. Participants saw the need to create an organisational culture where people work together toward success, and this indicated their awareness of the importance of adaptability in change. This requires transformational leadership that involves the enactment of behaviours that inspire followers to perform beyond expectations.[8] Participants found that having a vision helped leaders and their teams to become inspired and committed to a shared goal of quality education. Effective leadership is an essential attribute for the provision of professional and high-quality education. Certain factors contribute to effective leadership, and the findings indicated that a leader cannot exist in isolation, as effective interpersonal relationships are needed. Some of these relationships are with peers, and participants mentioned that peer support could provide opportunities to develop teamwork that could enhance the quality of services rendered in the university setting. A study in Ireland[9] also confirmed that having peers support one another, especially during challenging times, is very valuable. Support can also be seen in a two-way relationship, which could be established through consultation. Consultation is bidirectional, and provides individuals with a voice to openly exchange information, which leads to development within a group.[10] The participants experienced their own unique journey while working in different departments as they used their intuition to lead themselves. The intuition of man informs him of the existence of ‘something within’ which transcends all intellectual knowledge and reasoning processes, but which is perceived to be ever-present at the very heart of one’s being.[11] One should make wise choices in an academic environment. Professional and personal development originates from one’s own personal skills and expertise.[10] People need to be encouraged to develop the skills and competencies they require to become better workers, managers, entrepreneurs and innovators, who make wise decisions. In this study, the findings indicated that ‘making sense of things’ was part of selfleadership that shaped how academics understood themselves and their competencies. A leader’s abilities and values are related to how they structure tasks and manage the interpersonal relationships between other members of their department, which could impact the processes and ultimately the performance of a team[10] or faculty.

Conclusion

Leadership is no longer to be found only among organisational leaders, but also among academics. All the characteristics (masteries) of self-leadership

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Research described in Cashman’s[4] theoretical framework were mentioned by partici pants. Participants were self-aware of their leadership roles, and as leaders expressed who they were as individuals, and discussed their diverse leader ship experiences in the different departments. The experiences that the participants shared demonstrated a clear philosophy in the Faculty of Community and Health Sciences of focusing on leadership development and the succession of academics.

Acknowledgements. The authors would like to express gratitude to the staff members who participated in this study. Author contributions. KJ was the main author, with creative input from JF on the theoretical framework implemented. Funding. None. Conflicts of interest. None.

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1. Jooste K, Ahanohuo L, Arunachallam S, et al. The meaning of self-leadership for nursing academics of a research programme in the context of a higher education institution in the Western Cape. Afr J Nurs Midwifery 2015;17(1):122-133. https://doi.org/10.25159/2520-5293/238 2. Grint K. Leadership: Limits and Possibilities. Basingstoke: Palgrave Macmillan, 2005. 3. Bolden R, Gosling J, O’Brien A, et al. Academic Leadership: Changing Conceptions, Identities and Experiences in UK Higher Education. London: Leadership Foundation for Higher Education, 2012. 4. Cashman K. Leadership from the Inside Out. Provo: Executive Excellence Publishing, 1998:1-7. 5. Gerstberger RL, Gromala KA. How effective is utility leadership? J Am Water Works Assoc 2010;102(1):46-55. 6. Lichtenstein S. The Role of Values in Leadership: How Leaders’ Values Shape Value Creation. Integral Leadership review. http://integralleadershipreview.com/6176-the-role-of-values-in-leadership-how-leadersvalues-shape-value-creation/ (accessed 1 June 2016). 7. Baker B. What is Personal Mastery – A Look into Personal Development from a New Perspective. http:// www.startofhappiness.com/what-is-personal-mastery (accessed 2 April 2016). 8. Walsh M, Dupré K, Arnold KA. Processes through which transformational leaders affect employee psychological health. Ger J Resear Hum Resour Manage 2014;28(1-2):162-172. https://doi.org/10.1177/239700221402800109 9. Browne P. Bi-directional work to life conflict: An investigation of work life balance for nurses in acute public hospital settings in Ireland. Doctoral thesis. Galway: National University of Ireland, Galway, 2015. 10. Friedrich TM, Vessey WB, Schuelke MJ. A framework for understanding collective leadership: The selective utilization of leader and team expertise within networks. Leadersh Q 2009;20(6):933-958. https:// doi.org/10.1016/j.leaqua.2009.09.008 11. Parkinson S. The learning organisation as a model for rural development. Dev Pract 2010;20(3):329-341. https://doi.org/10.1080/09614521003709957

Accepted 7 September 2016.

Research

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

Clinical electives at the University of Michigan from the perspective of Ghanaian medical students: A qualitative study S Danso-Bamfo,1,2 MB ChB, MPH; N A Abedini,2 MD; H Mäkiharju,3 MA; K A Danso,4 MB ChB; T R B Johnson,5 MD; J Kolars,6 MD; C A Moyer,6 MPH, PhD Harvard T H Chan School of Public Health, Boston, Mass., USA; and Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass., USA Division of Hospital Medicine, Department of Internal Medicine, University of Washington, Seattle, Wash., USA 3 Hematology and Oncology Division, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA 4 School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana 5 Department of Obstetrics and Gynaecology, University of Michigan Medical School, Ann Arbor, USA 6 Departments of Learning Health Sciences and Obstetrics and Gynaecology, University of Michigan Medical School, Ann Arbor, USA; Global REACH, University of Michigan Medical School, Ann Arbor, USA 1 2

Corresponding author: S Danso-Bamfo (sdbamfo@gmail.com)

Background. Participation in international electives is an integral part of medical training for many medical students, yet little research explores the experiences of students from low-income countries who travel to high-income countries for medical electives. Methods. One hundred and two Ghanaian medical students who participated in 3 - 4-week clinical rotations at the University of Michigan between January 2008 and December 2011 were invited to participate in a mixed-methods study. Face-to-face, semi-structured interviews were conducted with 15 respondents from the larger group who agreed to take part in follow-up interviews. The 60- to 90-minute interviews were audio-recorded and transcribed verbatim, and transcripts were coded by three investigators in an iterative process of thematic identification, codebook generation and revision and consensus discussions. Results. Respondents described perceived differences between Ghana and the USA, including: exposure to ‘new’ aspects of medicine; differences between Ghanaian and US patients, healthcare workers, and patient-provider relationships; and aspects of the US system that they would like to see emulated in Ghana. Conclusion. This preliminary study suggests that international bilateral exchange programmes have lasting value for participants from low-income nations. Further research is needed to determine if the different types of experiences yield measurably different benefits. Afr J Health Professions Educ 2017;9(4):203-207. DOI:10.7196/AJHPE.2017.v9i4.827

Over the past few decades, the field of medicine has changed dramatically, reflecting changing disease patterns, increased ease of travel and growing interest in international health. Medical-school curricula have evolved accordingly, to include more international health experiences, in the form of electives, as a key feature for trainees.[1] However, most of these international electives are skewed towards students from the resource-rich nations of the Global North travelling to low-income countries.[2,3] The exact number of international opportunities available is unknown, but a clear disparity exists,[2] with very few opportunities for students from low-income countries to undertake international electives in resource-rich countries, particularly the USA. This inequality has raised concerns and led to an increased push for academic medical centres in high-income countries to become more involved in collaborative partnerships with medical centres in low-income countries.[3] Further concerns raised about the effect international health experiences have on host communities include students practising beyond their medical competence,[4] perpetrating a hero model in the host population[5,6] and working outside of national policies or priorities.[5] However, international medical experiences have also been shown to lead to the participants being more inclined to specialise in public

health or primary-care related fields, and students who have completed international clinical rotations often report a greater ability to recognise disease presentations, more comprehensive physical-examination skills with less reliance on expensive imaging, and greater cultural sensitivity.[6,7] Unfortunately, very little literature addresses the design and structure of international rotations for students from the Global South, and literature that examines the benefits for these students is almost non-existent. Based on the results of our previous quantitative analysis, where 97% of participants deemed their University of Michigan Medical School (UMMS) rotation as valuable to their medical training, and 90% reported changes in how they approach patient care, the investigators deemed it prudent to conduct a qualitative analysis of in-depth interviews to elucidate exactly what these changes were.[8]

History of the Ghana-Michigan medicalstudent exchange

The University of Michigan Department of Obstetrics and Gynecology has had a long-term partnership with the University of Ghana Medical School (UGMS), the Kwame Nkrumah University of Science and Technology

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Research School of Medical Sciences (KNUST-SMS), and Ghana’s Ministry of Health. It started through a Carnegie Foundation-funded programme, in partnership with universities and colleges of obstetricians and gynaecologists in the USA and the UK. The programme assisted in the development of postgraduate training in obstetrics and gynaecology in Ghana,[9] and the resulting partnership has provided opportunities for bilateral student and faculty exchanges, and created a platform for ongoing training, research and collaborative endeavours .[10] The programme has seen more than 80 students from Ghana rotate at UMMS between 2007 and 2011, and has expanded to include the University of Development Studies School of Medicine and Health Sciences (UDS-SMHS) and the University of Cape Coast School of Medical Sciences.

Structure of the Ghana-Michigan medicalstudent exchange

Ghanaian students typically spend 3 - 4 weeks in Ann Arbor, Michigan, participating in direct patient care and observation of clinical activities through rotations that are similar to those experienced by UMMS third- and fourth-year students, including the UMMS Simulation Centre. Students receive an orientation to the clinical environment, with topics such as utilisation of electronic medical records, sterile technique protocols and searching medical literature. Similarly, UMMS students undertake clinical electives at UGMS, KNUST-SMS or UDS-SMHS, commonly for a period of 4 weeks.

Methods

This study was reviewed and performed under an exemption granted by both the Ethical and Protocol Review Committee of UGMS (ref. no. MS-Et/ M.11-P.4.6/2010-11) and the University of Michigan Institutional Review Board (ref. no. HUM00048221). All participants gave electronic consent prior to participation.

Data collection

In late 2011, all 73 Ghanaian medical students from UGMS and KNUSTSMS who had participated in 1-month rotations between January 2008 and December 2010 were contacted via email and asked to complete a survey,[8] at the end of which, participants were given the option to be contacted for a follow up-interview. In mid-2012, invitations for interviews were also extended to a wider pool that included students who had subsequently completed rotations by August 2011, and students from UDS-SMHS. The 15 respondents who agreed to the follow-up were interviewed face-to-face for 60 - 90 minutes using a study-specific semi-structured interview tool and an audio recorder. To maintain anonymity, the interviewees’ names were not mentioned during the interview, and audio recordings were labelled anonymously and uploaded to a cloud-based file-sharing platform (Dropbox), from which they were accessed and transcribed by another member of the research team (HM).

Data analysis

The audio recordings of the interviews were transcribed verbatim, and transcripts were coded by three separate investigators (SDB, NCA, and CAM), as described by Charmaz.[11] Open codes were discussed and harmonised among the investigators, and a codebook was created to describe the codes. Transcripts were then coded using the identified coding schema, allowing room for further themes to emerge during the coding process. When additional codes arose, the team discussed the

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additional code and either amended the definition of an existing code or added a new code category to the codebook. Two of the investigators (SDB and CAM) discussed the hierarchy of codes, as well as any overarching themes.

Results

In-depth interviews with the 15 former medical students were completed in 2012, between 8 and 40 months after their rotation (mean = 16.7 months). This diverse group of eight women and seven men comprised five graduates of UGMS, six graduates of KNUST-SMS, and four graduates of UDS-SMHS, whose ages ranged from 24 to 29 years old, and was highly representative of the gender, age and medical-school affiliation of the general cohort of participants.[8] Respondents described perceived differences between Ghana and the USA with regard to the practice of medicine and the behaviours that they wished to emulate. The strongest themes identified in the data included: exposure to ‘new’ aspects of medicine; differences between Ghanaian and American patients; differences in the relationships and interactions between healthcare providers and patients, as well as among healthcare providers; and aspects of the US system that they would like to see emulated in Ghana.

Exposure to ‘new’ aspects of medicine

Many of the respondents described being exposed to new opportunities for further training that they had not been aware of before rotating in the USA. They also learned about subspecialties as well as new and emerging fields in medicine: ‘Before I went there I actually didn’t know there were so many specialties. I thought every obstetrics and gynaecology specialist was supposed to do everything […] I didn’t know that gynaecology was on its own, obstetrics was on it its own. I didn’t even know that infertility was on its own as a specialty, so yeah […] I [now] know there are more subspecialties around I can explore.’ (25-year-old female, UDS-SMHS)

Differences regarding patients, healthcare workers and their interrelationships Respondents described noticeable differences between Ghana and the USA regarding patient and provider demographics, the relationships between providers and their patients, and also between providers and trainees. They commented that some patients had done research on their illnesses and came to see the doctor ready with questions – something that would be uncommon in Ghana: ‘It’s a more literate community [in the USA] and so patients come knowing more about their condition, asking more questions and expecting to receive more response from the doctor. Doctors don’t impose too much of the decisions on patients, and patients form a very important part of the … clinical practice.’ (25-year-old male, UGMS) Respondents also commented on resident demographics, indicating that many of the residents and faculty in the USA were female, which is not the case in Ghana. ‘I was amazed that most of their residents [at Michigan] were females … even their chief resident was a female. I was very impressed because I want to do obstetrics and gynaecology but … not a lot of women rotate through that in Ghana and everybody says it’s quite difficult. But I was happy to see so many women doing the surgeries.’ (25-year-old female, KNUST-SMS)

Research One of the most common observations made by visiting trainees related to the differences between how medical students and faculty interacted in USA and Ghana. Respondents found that the relationship between ‘teacher’ and ‘student’ was less formal in the USA, and faculty were very accessible and approachable: ‘I didn’t expect them [the attendings] to be as eager and willing to help us as they were. They were very open, very ready to teach any opportunity they had. They were gentler if you made a mistake.’ (27-year-old female, KNUST-SMS) Respondents noted that this difference in interaction style had a significant effect on them as learners: ‘Personally … I think it boosted my self-esteem. It was like, “Oh so you can approach people like this and then talk freely?”’ (28-year-old male, UGMS)

Differences in learning environment

Respondents spoke about differences in the physical learning environment, particularly, the speed and efficiency with which procedures were done and the state-of-the-art machines that were in use, including automated dictation: ‘You got the history on a sheet of paper, nicely typed, you know, printed out. And to me I think it was nice. It was a way of making things more efficient so that I don’t waste time.’ (28-year-old male, UGMS) Trainees also commented on the speed with which laboratory results were available, and the advantages of having a computerised medical-records system: ‘In Ghana [in the morning] we have to go and see the patient immediately to open the folders, to see what the doctors have written … but there you can easily go back and look at their various investigation, labs, and consultations that have been done, and then you just go to the patient and ask a few pertinent questions, then just put your findings together and then just present it to the fellow or the attendant. I find that really as a step beyond what I find in Ghana here.’ (24-year-old male, UGMS)

Areas for improvement

Some respondents also mentioned certain aspects of their experience as less than desirable. The most common complaints were about the amount of hands-on clinical engagement they had, as well as limited contact with local medical students: ‘When we had our letters, it said we were coming mainly in an observatory capacity, but for some reason I thought I would get to do more than I got to do … so for me that was kind of, like, a disappointment because it gets boring when you are only watching people all the time, you’re not really doing much.’ (25-year-old female, UDS-SMHS) Trainees also mentioned organisational lapses as one area of potential improvement. In particular, students reported variability in terms of expectations: ‘Sometimes it’s like OK, you get there today, but it’s like quite undefined. You don’t really know whether today you should be going here or be going there. You know sometimes, but I think … those things should be streamlined properly.’ (28-year-old male, UGMS)

Potential applications at home

Overall, respondents reported learning behaviours that they felt were worth emulating. This included paying more attention to infection control, punctuality, improving the way they relate to patients and being more mindful of how they as individuals can improve the health outcomes of their patients. Infection control Interviewees reported the desire to improve certain aspects of the hospital setup in Ghana that were related to controlling the spread of infections. These included: hand-washing, the use of antibacterial solutions to disinfect hands and limiting the number of people allowed into the theatre to watch surgeries: ‘I don’t think it will cost much for the hospital to provide sanitisers all around … so I think it is a very achievable thing that we can use to prevent infection control … it is something we can apply without spending money.’ (24-year old-male, UGMS) Punctuality The interviewees reported that punctuality is highly regarded in the USA and they desired to emulate such ideals in Ghana: ‘That is one thing that I think I’ve gotten to appreciate. That if you have, if you work within the time that you have, as timely as you can, then you would be able to actually achieve everything that you are trying to do.’ (26-year-old female, KNUST-SMS) Empathy Another area that trainees repeatedly mentioned was witnessing providers’ empathy and kindness toward patients and wanting to be sure to do that more in Ghana: ‘What I saw from the interaction between workers, health workers and patients was a certain level of respect … you wouldn’t see a doctor or a nurse being rude to a patient or shouting at him. I really hope to put this into practice because a lot of times our patients just come and they need someone to be nice to them.’ (25-year-old male, KNUST-SMS)

Discussion

The majority of Ghanaian trainees who completed rotations at UMMS and participated in this study deemed the experience of their overseas rotation valuable. Few other studies have explored international health experiences from the perspective of students from the Global South, which is one of the main strengths of this study. Our interviewees formed a balanced sample, with both male and female students from three different participating schools. Furthermore, we conducted follow-up interviews as long as 2 - 3 years after trainees’ international health experiences, and in this regard, our study was able to solicit the views of students who had recently returned from the exchange as well as those who had undertaken it several years before. We were therefore able to see both the short- and medium-term impacts of the experience, particularly with regard to the influence it has had on the final leg of their medical training, their professional lives and postgraduate plans. One common theme that arose was of potential application of the lessons learned at home, which we termed ‘translation’. It describes the desire several students expressed of wanting to import certain aspects of what they had learned at UMMS and apply it at their home institution. The theme of

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Research translation included: paying more attention to infection control; improving ‘system factors’ such as orderliness and punctuality; and being more empathetic toward patients. We found that while there are many advantages to a truly bilateral exchange relationship for trainees from under-resourced settings, the design of such a programme is critical to its success. Apart from a few articles, such as those by Crump and Sugarman[12] and Bishop and Litch,[13] little attention has been paid to the ethical considerations necessary to ensure that North-South training or education initiatives have minimal undesirable effects on the relatively disadvantaged partner. Additionally, to help guide the design of ethically sound North-South medical partnerships, Crump and Sugarman,[14] as part of the Working Group on Ethics Guidelines for Global Health Training (WEIGHT), have developed a set of guidelines for institutions, trainees and sponsors of field-based global health training on ethics and best practices (Table 1) that we believe is a laudable starting point for any institution that is already engaged in or considering engaging in medical exchanges. While the Ghana-Michigan exchange programme has been beneficial, it is not without its challenge, one of which is the trainee’s level of engagement in clinical care while rotating in the USA. Improving efforts to genuinely integrate visiting trainees into patient management is an important learning point for those developing exchange programmes, especially in the face of regulatory and medicolegal challenges that may limit what visitors are allowed to do. While such integration may be difficult in some situations, it is undoubtedly the best way for trainees to maximise their learning. Another challenge relates to the organisational structure, and the need to ensure that

all participating attending faculty and residents understand the programme and the role of the visiting trainees.

Study limitations

As with all studies, we recognise that our study had some limitations, namely the small sample size and the possibility of people being predisposed to give positive answers when being interviewed face-to-face. We attempted to mitigate the risk of social desirability bias by using a Ghanaian interviewer who was also a part of the larger Ghana-Michigan exchange cohort. Given the balance of positive and negative comments recorded, we believe that this strategy was successful in limiting potential biases. We also recognise that our study could be strengthened if we could link participants to their ultimate residency training choice or specialty area of practice; however none of the participants interviewed had entered residency programmes at the time of data collection and as such our study can yield only a relationship between participation in the exchange programme and plans (or the lack thereof) for specialisation and not the participants’ ultimate specialisation choice. It is also possible that the study design – qualitative interviews with a small subset of the participants within a few years of the experience – precludes the observation of other potential outcomes associated with the exchange programme, for example, an exploration of the effects of an increased desire for subspecialisation among exchange participants. It could spark the development of additional in-country training programmes – as we have seen with the addition of the Reproductive Health and Family Planning

Table 1. Selected guidelines proposed by the Working Group on Ethics Guidelines for Global Health Training (WEIGHT)[14] Trainees

Host/sending institutions