AJHPE Vol 10, No 1 (2018) by HMPG

African Journal of Health

Professions Education June 2017, March 2018,Vol. Vol.9 10, No.No. 2 1

Scholarship of Africa for Africa

ISSN 2078 - 5127

AJHPE African Journal of Health Professions Education March 2018, Vol. 10, No. 1

EDITORIAL 2

Clinical education and training: Have we sufficiently shifted our paradigm? A Rhoda

FORUM 3

Adopting a role: A performance art in the practice of medicine L Schweickerdt

Medical education units: A necessity for quality assurance in health professions education in Nigeria A O Adefuye, H A Adeola, J Bezuidenhout

SHORT RESEARCH REPORT

10 A survey of radiation safety training among South African interventionalists A Rose, W I D Rae

RESEARCH

13 Physiotherapy clinical education at a South African university V Chetty, S Maddocks, S Cobbing, N Pefile, T Govender, S Shah, H Kaja, R Chetty, M Naidoo, S Mabika, N Mnguni, T Ngubane, F Mthethwa 19 Creating opportunities for interprofessional, community-based education for the undergraduate dental therapy degree in the School of Health Sciences, University of KwaZulu-Natal, South Africa: Academics’ perspectives I Moodley, S Singh 26 Health education on diabetes at a South African national science festival M Mhlongo, P Marara, K Bradshaw, S C Srinivas 31 Engagement of dietetic students and students with hearing loss: Experiences and perceptions of both groups Y Smit, M Marais, L Philips, H Donald, E Joubert 38 The perspectives of South African academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training S M Govender, M Mars 44 Comparing international and South African work-based assessment of medical interns’ practice K L Naidoo, J van Wyk, M Adhikari 50 ‘Sense of belonging’: The influence of individual factors in the learning environment of South African interns K L Naidoo, J van Wyk, M Adhikari 56 The effect of undergraduate students on district health services delivery in the Western Cape Province, South Africa S Reid, H Conradie, D Daniels-Felix 61 A new way of teaching an old subject: Pharmacy Law and Ethics S Chetty, V Bangalee, F Oosthuizen 66 Transition-to-practice guidelines: Enhancing the quality of nursing education T Bvumbwe, N Mtshali

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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 Susan van Schalkwyk Stellenbosch University Elizabeth Wolvaardt University of Pretoria

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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 CHIEF OPERATING OFFICER Diane Smith I Tel. 012 481 2069 Email: dianes@hmpg.co.za ONLINE SUPPORT Gertrude Fani Email: publishing@hmpg.co.za FINANCE Tshepiso Mokoena HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Mrs H Kikaya, Dr M Mbokota, Dr G Wolvaardt ISSN 2078-5127

Editorial

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

Clinical education and training: Have we sufficiently shifted our paradigm? In 2010, almost a decade ago, Frenk et al.[1] reported that health professions education needs to be transformed to appropriately address the health needs of the population in the 21st century. The authors further suggested that a competency-based curriculum would facilitate this transformation process.[1] The competencies that should be facilitated in such a curriculum should be aligned with the roles that health professionals need to fulfil to respond to the population’s health needs. These above-mentioned roles include being a collaborator, manager, health advocate, good communicator, professional and scholar.[2] It is therefore important that the clinical education and training component of health professions education programmes includes learning outcomes, teaching and learning activities, as well as assessment tasks that would facilitate the development of these competencies. The articles in this edition of AJHPE report on a number of aspects related to clinical education and training. The papers provide insights into approaches and models of clinical education, as well as the different learning activities students engage in as they become competent practioners. The aspects of an integrated model of clinical education are explored by Chetty et al.,[3] while additional perspectives about interprofessional education and practice are provided by Moodley and Singh.[4] Data relating to effectiveness and experiences of students acting as advocators of good health are reported on by Mhlongo et al.[5] and Smit et al.[6] The exploration of teaching and learning activities, such as telehealth[7] and performance art,[8] demonstrates that educators continue to examine different innovative methods to develop competencies of health professions students. Using both qualitative and quantitative methodologies, the samples reported on in the published articles include a variety of professions, such as pharmacy, dentistry, physiotherapy and dietetics. The inclusion of studies related to interns by Naidoo et al.[9,10] indicates that research in the field of health professions education extends beyond undergraduate programmes. Even though the main objective of clinical education and training, which involves placing students on varied clinical platforms, is to develop specific clinical competencies in students, the positive impact of having students on a specific clinical platform is reported on by Reid et al.[11] This is an important aspect to consider in settings where human resources for health are limited. As we read the information shared with us in this edition of AJHPE and reflect on initiatives implemented by health professions educators, such as interprofessional education and collaborative practice,[12] we need to ask how far we have come with training students who can address the health

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needs of the population in the 21st century, and, moreover, if graduates are equipped with skills to address the existing healthcare disparities.[13] If we are serious about the competencies needed by health professions graduates to meet the needs of communities in the 21st century, we need to continually review how we design and implement clinical education and training programmes. We might need to further shift our paradigms with regard to the manner in which we view clinical education and training. Information provided by articles in this edition of AJHPE could contribute to this paradigm shift. Anthea Rhoda Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa arhoda@uwc.ac.za 1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(4):1958-1923. https://doi.org/10.1016/S01406736(10)61854-5 2. Frank JR, Snell L, Sherbino J, eds. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada, 2015. 3. Chetty V, Maddocks S, Cobbing S, et al. Physiotherapy clinical education at a South African university. Afr J Health Professions Educ 2018;10(1):13-18. https://doi.org/10.7196/AJHPE.2018.v10i1.987 4. Moodley I, Singh S. Creating opportunities for interprofessional, community-based education for undergraduate dental students within the School of Health Sciences at the University of KwaZulu-Natal, Durban, South Africa: Academics’ perspectives. Afr J Health Professions Educ 2018;10(1):19-25. https//:doi.org/10.7196/AJHPE.2018. v10i1.974 5. Mhlongo M, Marara P, Bradshaw K, Srinivas SC. Health education on diabetes at a South African national science festival. Afr J Health Professions Educ 2018;10(1):26-30. https://doi.org/10.7196/AJHPE.2018.v10i1.887 6. Smit Y, Marais M, Philips L, Donald H, Joubert E. Engagement of dietetic students and students with hearing loss: Experiences and perceptions of both groups. Afr J Health Professions Educ 2018;10(1):31-37. https://doi. org/10.7196/AJHPE.2018.v10i1.901 7. Govender SM, Mars M. The perspectives of South African academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training. Afr J Health Professions Educ 2018;10(1):3843. https://doi.org/10.7196/AJHPE.2018.v10i1.957 8. Schweickerdt L. Adopting a role: A performance art in the practice of medicine. Afr J Health Professions Educ 2018;10(1):3-4. https://doi.org/10.7196/AJHPE.2018.v10i1.950 9. Naidoo KL, van Wyk J, Adhikari M. Comparing international and South African work-based assessment of medical interns’ practice. Afr J Health Professions Educ 2018;10(1):44-49. https://doi.org/10.7196/AJHPE.2018. v10i1.955 10. Naidoo KL, van Wyk J, Adhikari M. ‘Sense of belonging’: The influence of individual factors in the learning environment of South African interns. Afr J Health Professions Educ 2018;10(1):50-55. https://doi.org/10.7196/ AJHPE.2018.v10i1.953 11. Reid S, Conradie H, Daniels-Felix D. The effect of undergraduate students on district health services delivery in the Western Cape Province, South Africa. Afr J Health Professions Educ 2018;10(1):56-60. https://doi. org/10.7196/AJHPE.2018.v10i1.959 12. Frantz JM, Rhoda AJ. Implementing interprofessional education and practice: Lessons from a resourceconstrained university. J Interprof Care 2017;31(2):180-183. https://doi.org/10.1080/13561820.2016.1261097 13. Mayosi BM, Benatar SR. Health and health care in South Africa – 20 years after Mandela. N Engl J Med 2014;371:13441353. https://doi.org/10.1056/NEJMsr1405012

Afr J Health Professions Educ 2018;10(1):2. DOI:10.7196/AJHPE.2018.v10i1.1080

Forum

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Adopting a role: A performance art in the practice of medicine L Schweickerdt, BA Drama Hons Skills Centre, School of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa Corresponding author: L Schweickerdt (louise.schweickerdt@smu.ac.za)

The practice of medicine has evolved a long way from its origin, where healing was practised as an art in ancient Greece. In current healthcare training, the focus is on clinical features and the treatment thereof. The connection to the arts in the practice of medicine has been lost – one of the reasons why students of medicine lose their empathy during their years of training. In this article, I explore the correlations between the art of performance and medicine, with particular focus on the training of students of medicine. The notion is investigated that if medical students learn to adopt a professional role by incorporating certain non-assuming facets of the art of performance into their training, they could learn to step in and out of the role of healthcare practitioner (HCP). This action could assist them not only in reflecting on their practice as HCPs, but could also afford them the opportunity of debriefing, as they are equipped with the tools to view their role as HCPs more objectively. The acquisition of tools to step in and out of the role of HCP, complemented by the process of debriefing through reflection, could afford students of medicine the ability to deal with the emotional labour that training to become a future HCP brings. In turn, this may empower them to retain the empathy that they inherently possessed when they enrolled as students. Afr J Health Professions Educ 2018;10(1):3-4. DOI:10.7196/AJHPE.2018.v10i1.950

In ancient Greece, where western medicine originated, rituals of healing took place in the form of performances – with an observing audience.[1] Greek physicians believed in the importance of the role of theatre in the treatment of illness.[2] The connection between the art of healing and the art of performance, which was formed in ancient Greece, still exists,[3-5] as also becomes apparent when considering that an operating theatre and a performance theatre are both still referred to as ‘theatres’. However, modern healthcare training focuses predominantly on clinical features and the treatment thereof, which is one of the reasons why students of medicine lose their empathy during their training.[4,5] The acquisition of tools to step in and out of the role of a healthcare practitioner (HCP), could equip students of medicine with the ability to ‘reflect on their own thoughts, feelings, inclinations, practice and experience’.[6] This could be regarded as a process of debriefing, as it will allow them to reconnect with their ‘inner selves’ outside the scope of their role as HCPs. By drawing attention to aspects of the art of performance in relation to healthcare training, this article explores the notion that, if students of medicine are trained in a way that enables them to reconnect with the art of performance, they could learn to adopt a role that will equip them with the necessary tools to cope with the emotional labour that their training requires.[3,5]

Adopting a role

In The Presentation of Self in Everyday Life, Goffman[3] investigates the concept of roles that human beings adopt, specifically when they need to adhere to a social structure confined to a building or a space. Goffman refers to white coats as creating the impression that the manner in which tasks ‘performed’ by persons wearing such coats are standardised, clinical and confidential.[3] Donning a white coat, adding a stethoscope and other features of medical care, could afford students of medicine the possibility of stepping into the role of a HCP while simultaneously stepping

away from the self – just as an actor’s costume and make-up assist in transforming them into the character to be portrayed. Goffman[3] also refers to a ‘setting’, which is a space that includes ‘furniture, décor, physical layout and other background items which supply the scenery and stage props for the spate of human action played out before, within or upon it’. This setting might refer to a set on stage that allows the actor to believe in the world of the drama that is about to unfold, as his visual perception contributes to the belief in his surroundings. Medical students might learn to adapt to the setting in a hospital or consultation room in a similar manner: a setting reminding them that they are surrounded by an environment that offers certain prerequisites for them to take on the role of a HCP. Sinclair,[4] a medical doctor and anthropologist who returned to medical school to observe how students are trained, draws detailed similarities between the art of performance and that of medicine. According to him, a strong connection between healthcare and the art of performance is suggested in the theatrical setting of ward rounds. Students learn to present their patients before the ears and eyes of an audience.[4] Apart from the performance aspect that Sinclair[4] refers to, the acquisition of medical terminology corresponds to the actor’s internalisation of a stage script. Neither the medical student nor the actor uses their own words. Their inner selves can hide behind medical terminology or script. The revolutionary director of the Russian stage, Constantin Stanislavski,[7] dealt at length with the notion of the ‘magic if ’. The actor must remain authentic by acting ‘as if ’ he found himself in the situation that the character is in. Stanislavski’s ‘system’ – or representational acting – stands in strong contrast to the Strasberg[8] ‘method acting’. In Strasberg’s method, the actor immerses his entire being into the character he is portraying. The line between the character and the actor’s psyche becomes inextricably intertwined until it eventually dissolves and the actor is left in a state of confusion, with little or no connection to their own personal feelings. A comparison may be drawn between ‘method’ actors and students of

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Forum medicine who lose touch with their inner selves in an attempt to immerse themselves into their medical identities as HCPs. A strong correlation can also be drawn between Stanislavski’s system and Strasberg’s method and the role that students of medicine could adopt. Instead of immersing themselves into the world of their training, such as a method actor would do, students of medicine could be trained to adopt a role such as explained by Goffman[3] or Stanislavski’s ‘magic if ’. In turn, this could afford medical students the possibility of stripping the role when they leave work to return to an area that Goffman[3] refers to as ‘outside’ and Sinclair[4] refers to as the ‘lay world’. These are areas that bear no connection to any areas or settings where a professional role needs to be adopted.[3,4] In theatrical terms, it could be the space that an actor returns to after having performed a role. These areas could offer the actor or students of medicine the possibility of rehabilitating the self through reflection as a means of debriefing.[6] Here, students of medicine could internalise the experience, incorporating it as part of who they are when they do not need to adopt or portray the role of a HCP. Hence, this could assist them not to become overwhelmed by unresolved emotions so that the emotional labour required to be trained as a future HCP does not become too much to bear, with the loss of empathy as consequence.[4,5]

Conclusion

The practice of medicine has evolved from its origin, where healing was practised solely as an art in ancient Greece. Currently, healthcare training focuses predominantly on clinical features and the treatment thereof. Students of medicine could benefit if they are given the tools to adopt a role as HCP instead of attempting to immerse themselves in the medical identity of a HCP.[3,4] Incorporating some non-assuming facets of the art of

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performance into the training of medical students could assist them with the ability to step in and out of the role of HCP, which could afford them the opportunity to reflect on their actions to gain new insights into the strengths and weaknesses of their own practices.[6] The process of reflection could be regarded as a strategy to debrief, which could provide them with the tools to deal with the emotional labour that the work demands.[5] This could enable them to retain the empathy they inherently possessed when they enrolled as students of medicine. Acknowledgements. I am deeply indebted to Prof. Ina Treadwell, without whose insight and strong support none of this work would have been possible. I would also like to express immense gratitude towards Dr Champak Barua for believing in the concept and his selfless sharing of knowledge throughout the process. Author contributions. Sole author. Funding. None. Conflicts of interest. None. 1. Clift S, Camic PM, eds. Oxford Textbook of Creative Arts, Health and Wellbeing. Oxford: Oxford University Press, 2016. 2. Christos FK, Sfakianakis C, Papathanasiou IV. Health care practices in ancient Greece: The Hippocratic ideal. J Med Ethics Hist Med 2016;7(6):1-6. 3. Goffman E. The Presentation of Self in Everyday Life. New York: Random House, 1959. 4. Sinclair S. Making Doctors: An Institutional Apprenticeship. Oxford: Berg Publishers, 1997. 5. Riley R, Weiss MC. A qualitative thematic review: Emotional labour in healthcare settings. J Adv Nurs 2015;72(1):6-17. https://doi.org/10.1111/jan.12738 6. Kirklin D. Humanities in medical training and education. Clin Med 2001;1(1):25-27. https://doi.org/10.7861/ clinmedicine.1-1-25 7. Stanislavski C. An Actor Prepares. New York: Routledge, 1964. 8. Strasberg L. A Dream of Passion: The Development of the Method. Boston: Little, Brown, 1987.

Accepted 16 August 2017.

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Medical education units: A necessity for quality assurance in health professions education in Nigeria A O Adefuye,1 MB ChB, MSc, PhD (Med); H A Adeola,2,3 DDS, PhD (Med); J Bezuidenhout,1 BA (Ed), MEd, DTech (Ed), PGD (HPE) 1

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

Department of Oral and Maxillofacial Pathology, Faculty of Dentistry, University of the Western Cape, Cape Town, South Africa, and Tygerberg Hospital, Cape Town, South Africa

Division of Dermatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, and Groote Schuur Hospital, South Africa

Corresponding author: A O Adefuye (AdefuyeAO@ufs.ac.za)

In recent years, curricula and pedagogical methods in medical education have undergone rapid and unprecedented changes globally. The emphasis has shifted from traditional, teacher-centred learning, characterised by the accumulation of non-integrated volumes of knowledge, to active, student-centred learning. The Medical and Dental Council of Nigeria (MDCN) reports that there are 31 fully accredited and 6 partially accredited medical schools in Nigeria. The majority of these medical schools still offer undergraduate medical training based on a curriculum characterised by a distinct separation of preclinical and clinical training, with minimal or no integration. This approach is coupled with low-quality teaching by medical educators, as many medical colleges in Nigeria presently use specialists as lecturers who have little or no training in higher education practices; their only exposure to teaching is that obtained during their postgraduate specialty training. Similarly, very few medical schools in Nigeria have established medical education units (MEUs), as recommended by the World Health Organization and the World Federation for Medical Education. We discuss the shortcomings of the present medical education system in Nigeria and suggest ways to improve the quality of pedagogy among Nigerian medical educators, such as the establishment of clinical-skills centres and MEUs at Nigerian medical schools. In addition, this review highlights the role and importance of MEUs in facilitating quality assurance in health professions education, and the urgent need for more medical schools in Nigeria to establish MEUs to promote, co-ordinate and evaluate medical education reforms based on needs assessments and within the confines of MDCN standards. Afr J Health Professions Educ 2018;10(1):5-9. DOI:10.7196/AJHPE.2018.v10i1.966

As reported in the Edinburgh Declaration on Medical Education of 1988,[1] the main goal of any medical education programme is to produce clinicians who will promote the health and well-being of all people adequately, and not merely deliver curative medical services. Therefore, quality assurance in health professions education and social accountability should be part of every country’s ethical responsibility.[2] Physicians graduating from medical colleges must be competent clinicians, clinical thinkers, critical thinkers, self-directed learners, team players, effective communicators, problemsolvers and collaborators if they are to provide high-quality medical care within clearly defined criteria of minimally accepted standards.[3] However, many middle- to low-income nations, including Nigeria, have failed to achieve this goal, and are not aligned with the enormous advances in biomedical sciences that are taking place elsewhere. Of great concern is the claim that graduates of medical colleges in Nigeria who trained under the present curriculum may lack the skills and aptitude required for success in the changing practice environment of the 21st century.[4] In response, the Nigerian Federal Ministry of Health, in conjunction with the Medical and Dental Council of Nigeria (MDCN) and the National University Commission (NUC) have, on several occasions, set up committees in an attempt to review the medical and dental education curricula in the country.[4] This has, however, not yielded any favourable results.[5,6] The failure of these committees/meetings therefore necessitates a new approach to improving the quality of medical education in Nigeria. There is an urgent need to pay particular attention to matters of medical education and educator training.

Medical practice and medical education in Nigeria

The MDCN remains the main regulatory body for medical and dental practice in Nigeria. It was established by the Medical and Dental Practitioners’ Act of 28 June 1988 (CAP M8 LFN 2004) to replace the Nigerian Medical Council established by the Medical and Dental Practitioners’ Act of 18 December 1963.[7] The mandates of the MDCN are to regulate training and practices in medicine, dentistry and alternative medicine in Nigeria; determine the knowledge and skills of health professionals; and to regulate and control laboratory medicine in Nigeria.[7] While the various universities/colleges of health sciences are at liberty to establish academic/medical education programmes at undergraduate level, the MDCN remains the only authority empowered to approve courses, institutions and qualifications intended for persons seeking to be registered as health professionals.

Medical curricula and pedagogical methods of medical education in Nigeria

According to the MDCN, there are 31 fully accredited and 6 partially accredited medical schools in Nigeria. Nine of the 31 fully accredited Nigerian medical schools have dental schools, of which 7 are fully accredited and 2 have partial accreditation. While the development of medical curricula remains the sole responsibility of the senates of the individual universities, the MDCN and the NUC are mandated to determine the minimum standards of these curricula. Historically, the MDCN and NUC employ dissimilar approaches to medical education, owing to differences in

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Forum their targets and priorities. These contrasting interests, as presented below, of the dual monitoring bodies for medical education in Nigeria present a dilemma (Table 1). The expected learning activities during a programme of study or a course that results in the acquisition of knowledge and skills is known as a curriculum.[9] Some of the capacities enabled by the design of a curriculum include determining professional and educational context for programme development and delivery; aligning the needs of learners and the expectations of professional bodies; determining learning outcomes; recognising constraints; determining the areas of learning and teaching; reviewing the modules based on feedback; and determining the topic sequence and key examinations.[9] Over the years, emphasis and trends in planning and design of the medical curriculum and pedagogical methods in medical education have shifted, from traditional passive (teacher-centred) learning, characterised by the accumulation of non-integrated volumes of knowledge, to an active (self-directed/student-centred), systematic approach.[10-13] Though Nigeria is the most populous nation in Africa and has four generations of medical schools, not much has changed in the blueprint of the medical education curriculum since the inception of the first medical school in 1948.[5] There has not been any systematic training pathway for medical educators; nor has there been significant curriculum review or planning. Although, on paper, regulatory bodies such as the NUC and MDCN have proposed modifications of the traditional medical education curriculum in line with regional and global standards, there has been a varying degree of response towards medical curriculum review.[5] The Federal Ministry of Health of Nigeria, supported by the United States Agency for International Development (USAID), under the flagship of the Health 20/20 project, developed the Nigeria Undergraduate Medical and Dental Curriculum Template, 2012, from which individual schools could develop their own curriculum de novo.[14] This curriculum template boasts being a home-grown, needs-assessment-based, integrated, systembased, person-centred, community-oriented and competency-driven model, meant to provide medical students with the best possible learning opportunities and to produce competent medical graduates. Major revision of medical/dental curricula is recommended every 5 years, owing to the diminishing lifespan of useful medical information and the increasing complexity of medical practice.[15] Reviewing a medical curriculum is a complex process that involves human, capital and time resources.[16] For example, the revision of the traditional Bachelor of Medicine and Bachelor of Surgery (MBBS) curriculum to a competency-based curriculum (CBME; competency-based medical education) at the College of Medicine, University of Ibadan, took approximately 12 years (2001Â - 2012), in a series of overlapping

processes.[15] Few medical colleges in Nigeria have access to the necessary resources (human, capital and time), which causes curriculum stagnation.[6] The current medical education curriculum in use at most medical colleges in Nigeria involves 2 and 4 years of preclinical and clinical training, respectively. Each of these stages is followed by an examination in the form of written, practical/clinical and oral (viva voce) exams. Some medical schools have introduced objective structured clinical exams or objective structured practical exams into their student assessment, which improve objective evaluation of students, compared to long and short cases methods of assessment. There is a lack of integration between the preclinical and clinical curricula in most medical schools, making it difficult to harness the skills and experience acquired at both levels of training.[5] This lack of integration is exacerbated by the fact that the medical educators are specialists with little or no training in higher education practices,[17] and whose only exposure to teaching is that obtained during their postgraduate training.[6] Most lecturers lack training in modern educational methods, and therefore cannot improve their teaching output, leading to poor student outcomes.[6] There is therefore an urgent need for compliance with global shifts in medical curricula, in order to improve the training and evaluation of medical doctors and dentists in Nigeria.

Shortfalls of the present system and suggested solutions

The shortfalls of the present medical education system in Nigeria are outlined below. (i) Medical curricula and pedagogical methods: These still follow an opportunistic approach, leading to curriculum overload and atrophy.[15] (ii) Staff quality: This is not optimal, and there is a paucity of systematic training programmes for medical educators. The only requirement of the current system is that doctors who train medical students possess medical specialist qualifications, irrespective of whether these educators are wellequipped or even willing to train undergraduates. (iii) Quality of medical doctors: This is not consistent, owing to the lack of standards vis-Ă -vis medical curriculum approval and medical school accreditation, and the quality of medical doctors produced by the different medical schools.[5] Institutions in the medical sector lack adequate and modern learning and evaluation facilities.[6] (iv) Unreliable forms of assessment: The viva voce examination has been used subjectively as a victimisation tool to punish students perceived to be disrespectful to their teachers.[18] Furthermore, oral examinations have been demonstrated to have low reliability as an assessment tool for clinical competence.[19] Another inconsistency relates to the fact that some examiners are generous when marking oral exams, while others are not.[19] Although it

Table 1. Contrasting interests of the dual monitoring bodies for medical education in Nigeria National University Commission (NUC) Prefers a course credit system and wants all medical teachers to be in possession of a PhD before promotion into senior academic positions. Would like to grow the quota intake of medical students per year. Prescribes minimum academic standards, and ensures, through periodic monitoring, that training institutions adhere to these minimum standards.

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Medical and Dental Council of Nigeria (MDCN) Does not support these requirements.[6] Wishes to ensure that the available facilities are able to accommodate such increases without compromising the quality of graduating doctors.[6] Minimum requirements have been set by the MDCN in terms of student intake, minimum physical facilities, learning resources, administrative facilities and teaching staff requirements.[8]

Forum has been postulated that the use of long case/short case as a form of assessment appears to be suitable for situations where resources are limited,[14] its subjectivity makes it highly unreliable as an assessment tool. Considering that professional development progress depends on a grounded relationship between continued educational activity and performance, a practical framework that could be used for evaluating competencies/skills at Nigerian medical schools is Miller’s Pyramid, which employs multilevel achievement steps, starting with knowledge at the bottom and ending with competence at the top.[20] To tackle these problems, renewed efforts should be made to achieve greater synergy between the NUC and MDCN, medical educators should be mandated to undergo training in educational methods, and more medical colleges in the country should be supported to undertake curriculum reviews that reflect modern trends in medical education.

The need for medical education units at medical schools in Nigeria The Cape Town Declaration of 1995, which was the outcome of the African Regional Conference of the World Health Organization and the World Federation for Medical Education, states that medical (health sciences) education units (MEUs) should be established at every medical school, and that mechanisms should be put in place for promoting, co-ordinating and evaluating medical education reforms. Since then, independent MEUs or similar bodies have been established at medical schools across the African continent.[21, 22] Titles commonly given to these units include office, division, department, centre and unit.[23] However, very few medical schools in Nigeria have established MEUs.[21] This deficiency is evident from a 2007 study carried out by Ofeogbu and Ozumba,[21] which surveyed 26 accredited medical schools in Nigeria to determine whether they had independent MEUs. Of the 14 respondents, only 1 had a designated MEU. By 2017, the number of accredited medical schools in Nigeria had grown to 31 fully accredited medical and 7 dental schools.[7] However, a comprehensive online literature search for ‘medical education department or health science education unit or office or centre or division’ at medical schools in Nigeria, undertaken in the course of this review, revealed that only two medical schools, the College of Medicine, University of Nigeria, Enugu[21] and the College of Medicine, University of Ibadan, Nigeria,[24] have established MEUs. The activities of MEUs transcend educational levels, and encompass undergraduate, postgraduate and continuing medical education.[25] The roles of MEUs include teaching, programme evaluation, facilitating the use of educational technologies, planning, implementing and promoting educational (teaching and learning) development and supporting medical education research.[26] It has been suggested that establishing MEUs at medical schools in Nigeria will be a good starting point to stimulate strategy for curriculum transformation in order to improve the quality of health professions education.[24] On the basis of needs assessment, MEUs at individual medical schools can determine their training needs through constant curriculum reform and evaluation processes within the specified standards of the MDCN.[27] The purpose of medical education at all levels is to prepare knowledgeable and highly skilled healthcare professionals taxed with delivering safe and effective patient care.[28] The traditional learning model of medical education is undergoing a pedagogical shift, to a simulation-based medical education (SBME) learning model.[28] Not all medical educators in Nigeria are aware of the minimum standards for teaching and learning at both

undergraduate and postgraduate levels, including educational technologies that can be utilised.[29] SBME is an effective pedagogical tool that can be used to develop new skills, identify knowledge gaps, reduce medical errors and maintain infrequently used clinical skills, even among experienced clinical teams, with the overall goal of improving patient care.[28] Planning and establishing a simulation/clinical-skill centre that can train staff on the basic pedagogical principles of SBME and deliver it effectively will be the core role of the professional team situated at an MEU. However, the human, time and, particularly, the financial resources required to set up a dedicated simulation/clinical-skill centre might prove to be a challenge for most medical colleges in Nigeria. Nevertheless, overcoming these challenges will yield a rich return. In the area of research, MEUs can support health professionals/medical educators to conduct research in the field of medical education in their respective fields of practice.[30]

Steps toward establishing MEUs in Nigeria

Taking into consideration the variability in culture, geographical location and available resources, approaches to setting up MEUs at individual medical colleges across Nigeria may vary considerably. However, we suggest key steps and methods for setting up successful MEUs at medical schools in Nigeria.[29] (i) Conduct a needs assessment: The opinions of the various stakeholders in medical education (college executives, teaching and non-teaching staff, medical/dental students, employers of doctors and members of the public) of the individual medical college should be sought. The needs assessment could probe into the kind of health professionals (doctors, dentists, nurses or physiotherapists, for instance) needed by modern medical practice, the curricula required to produce the desired health professionals, the pedagogical methods in which the curriculum will be presented and the support needed to improve the quality of pedagogy among medical educators. (ii) Solicit appropriate administrative support: In the academic environment, establishing a new unit/division such as an MEU would generally require a great deal of administrative support from the dean and other powerful advocates within the medical school, such as the faculty management/board and university senate committee. Approaching a newly appointed dean for support might yield a positive result, as studies have shown that newly appointed organisational heads are keen to effect organisational change, and are receptive to implementing new innovations.[31] Lobbying for a dean’s support may involve presenting the results of the needs assessment study that justifies the establishment of an MEU, and making the necessary recommendations. Data can be gathered through questionnaire surveys, interviews (semi-structured or structured), focus group discussions, nominal group discussions and an expert Delphi survey, to attain consensus on salient topics. A thorough review of the existing literature, discussing the current strengths and weaknesses of current medical education systems and demonstrating practical ways in which establishing an MEU will benefit a department, could also be part of the needs assessment process. Recommendations should be made and reports produced on the way in which an established MEU can help attain anticipated goals, namely enhancing curriculum reform, improving staff skills regarding medical education and producing exceptional medical graduates who will meet the needs of society.

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Forum (iii) Nominate a technical working group (TWG): Nominating a TWG that will be taxed with working on various aspects of the project will be essential at the onset. Members of the TWG may include academic staff from the various departments within the faculty, and an education expert. (iv) Train staff and build capacity: Several members of the TWG may need to undertake formal training in medical education, both locally and internationally. Training could take the form of visits to other institutions with established MEUs, both locally and internationally. Such visits will enable networking that can lead to personnel development, academic stimulation, mutual support and practical demonstrations of what should be done and how it can be done.[29] (v) Conduct preliminary discussions with relevant regulatory bodies: These discussions on the role an MEU will play in the medical education arena, e.g. health professions education, staff development and research should be held with the MDCN and the NUC. (vi) Staff the MEU: The staff size and staff profile of an MEU will vary according to the unitâ&#x20AC;&#x2122;s roles in each institution.[26] On average, MEUs employ five or more academic staff with professional qualifications such as a PhD, DEd or MBBS/MB ChB and three or more support/administrative staff.[30] (vii) Obtain a mandate for funding for a few years before becoming selfsupporting: This mandate should be obtained from the governing body of the institution.[29] (viii) Attract financial resources: Resources could be obtained through grant incomes that can be used to support the activities of the unit, which could include multicentre research on medical education. (ix) Establish networks with other MEUs: These networks should be established both nationally and internationally. (x) Ensure a non-judgemental approach to members of the faculty: Creating a supportive, encouraging and facilitating approach will ensure acceptance of the newly created MEU.[29]

Factors hindering the establishment of MEUs at medical schools in Nigeria, and suggestions for solutions The challenges hindering the establishing medical education units at medical at medical schools in Nigerian are summarised below. (i) Financial hurdles: To create MEUs of uniform standard, quality and efficacy at Nigerian medical schools, the co-operation of the government, university, hospitals and private and international organisations to support the project financially is very important. Public-private support partnerships could be established by medical school authorities to reduce the financial burden of setting up and staffing an MEU. In addition, the financial burden can be defrayed by innovation and by improvising with resources already available at the respective medical schools. For example, mobile devices and newly emerging apps can be used for the dissemination of information to healthcare professionals, and for training medical educators and students.[32] As explained by Ofoegbu and Ozomba,[21] existing faculty members could be allowed to spend a percentage of their working time as ad hoc staff in the MEU. Because financial hurdles can constitute an impediment to setting up an MEU, the judicious use of existing resources is key. (ii) MDCN and NUC bureaucracy: A practical suggestion for overcoming NUC and MDCN bureaucracy is to establish a mutually agreed-upon minimum requirement for medical education and medical educators in Nigeria. A major contributing factor to the lack of progress in this regard is the dearth of qualified medical educators with appropriate training and

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qualifications in medical education. The dual authority of the NUC and MDCN should be actively directed towards establishing health professionalsâ&#x20AC;&#x2122; education units across the country. As it is sometimes the same individuals who perform accreditation for both MDCN and NUC,[6] these individuals should carry out these duties in a manner that harmonises the mandates of the two bodies. (iii) Lack of willingness to change: Medical educators are sometimes sceptical of the drastic changes that a revision of the curriculum by MEUs might cause, and fear that such changes would erode their busy clinical schedules. If this scepticism is prevalent at a medical school, the leadership of the school could engage MEU advocates to systematically engage faculty members on the benefits of having an independent MEU at the university. (iv) Sustainability: Once an MEU has been established, its success depends on the willingness of the institution and faculty members to sustain its existence and efficacy.[21] An independent evaluation of the efficacy of the MEU must be carried out periodically, possibly by the MDCN and/or NUC, and each MEU must strive to achieve excellence. (v) Leadership: To establish lasting reform in medical education via MEUs, a strong leadership structure is an essential requirement.[26] MEUs should be directed by leaders who are good role models and are able to motivate members of the MEU. In addition, such leaders should be visionaries, and remain professionally aligned to the development initiative of the MEU of the medical school. They should also be able to create good mentorship and collaborative research networks across the medical school. (vi) Research and service focus: MEUs should not only be dedicated to providing medical education services to the medical community, but also be constantly engaged in research.[26] A lack of research by an MEU could result in diminished innovation, and lead to the complete loss of its function.

Conclusion

This review highlights the role of and importance of MEUs in facilitating quality assurance in health professions education, and the urgent need for more medical schools across Nigeria to establish such MEUs to promote, co-ordinate and evaluate medical education reforms on the basis of needs assessment, and within the confines of MDCN standards. Medical curriculum and course design must be built on the premises of modern-day educational theories; this would promote the production of a communityoriented and competent health workforce,[33] and expand the learning and teaching experience of both the student and the medical teacher. Medical curricula should be designed to accommodate dynamic learning and teaching strategies, to produce customised medical practitioners who can maximise the resources available in order to serve in their own local environments. [33] Acknowledgements. None Author contributions. AOA conceptualised, designed, prepared and critically revised the manuscript, and HAA and JB were involved in the design and critical intellectual revision of the article. All authors read and approved the final manuscript submitted for publication. Funding. The Health and Welfare Sector Education and Training Authority (HWSETA), SA. Conflicts of interest. None. 1. Walton HJ. Edinburgh declaration and medical education. Lancet 1989;333(8629):105. https://doi.org/10.1016/ S0140-6736(89)91466-9

Research 2. Woollard RF. Caring for a common future: Medical schools’ social accountability. Med Educ 2006;40(4):301-313. https://doi.org/10.1111/j.1365-2929.2006.02416.x 3. Boelen C. Building a socially accountable health professions school: Towards unity for health. Educ Health 2004;17(2):223-231. https://doi.org/10.1080/13576280410001711049 4. Olasoji HO. Rethinking the approach to curriculum review in medical and dental education in Nigeria. J Educ Pract 2014;5(32):82-87. https://pdfs.semanticscholar.org/2d85/83f69aa6e7a54702578d22c87a2223d4a7f9.pdf (accessed 2 February 2017). 5. Ibrahim M. Medical education in Nigeria. Med Teach 2007;29(9-10):901-905. https://doi. org/10.1080/01421590701832130 6. Malu A. Universities and medical education in Nigeria. Niger Med J 2010;51(2):84-88. http://www.nigeriamedj. com/text.asp?2010/51/2/84/71004 (accessed 4 February 2017). 7. Medical and Dental Council of Nigeria. Medical and dental practitioners act CAP M8 http://www.mdcnigeria. org/Downloads/Cap%20M8.pdf (accessed 2 February 2017). 8. Medical and Dental Council of Nigeria. Guideline on Minimum Standards of Medical and Dental Education in Nigeria. The Red Book. Abuja: MDCN, 2006. 9. McKimm J, Barrow M. Curriculum and course design. Br J Hosp Med 2009;70(12):714-717. https://doi. org/10.12968/hmed.2009.70.12.45510 10. Harden RM, Sowden S, Dunn WR. Educational strategies in curriculum development: The SPICES model. Med Educ 1984;18(4):284-297. https://doi.org/10.1111/j.1365 2923.1984.tb01024.x 11. Goldie J. Review of ethics curricula in undergraduate medical education. Med Educ 2000;34(2):108-119. https://doi.org/10.1046/j.1365-2923.2000.00607.x 12. Gukas ID. Global paradigm shift in medical education: Issues of concern for Africa. Med Teach 2007;29(910):887-892. https://doi.org/10.1080/01421590701814286 13. Norman G. Medical education: Past, present and future. Perspectives Med Educ 2012;1(1):6-14. https://doi. org/10.1007/s40037-012-0002-7 14. Federal Ministry of Health of Nigeria (Health Systems 20/20 Project). Nigeria Undergraduate Medical and Dental Curriculum Template, 2012. Bethesda, Maryland: Abt Associates Inc., 2012. 15. Olopade FE, Adaramoye OA, Raji Y, Fasola AO, Olapade-Olaopa EO. Developing a competency-based medical education curriculum for the core basic medical sciences in an African medical school. Adv Med Educ Pract 2016;7:389-398. https://doi.org/10.2147%2FAMEP.S100660 16. Kiguli-Malwadde E, Olapade-Olaopa EO, Kiguli S, et al. Competency-based medical education in two sub-Saharan African medical schools. Adv Med Educ Pract 2014;5:483-489. https://doi.org/10.2147%2FAMEP.S68480 17. Olasoji H. Addressing the issue of faculty development for clinical teachers in Nigeria. Niger J Clin Pract 2014;17(2):265-266. https://doi.org/10.4103/1119-3077.127576 18. Bode C, Ugwu B, Donkor P. Viva voce in postgraduate surgical examinations in Anglophone West Africa. J West Afr Coll Surg 2011;1(1):40-52. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170249/ (accessed 31 August 2017).

19. Adeniyi OS, Ogli SA, Ojabo CO, Musa DI. The impact of various assessment parameters on medical students’ performance in first professional examination in physiology. Niger Med J 2013;54(5):302-305. https://doi. org/10.4103%2F0300-1652.122330 20. Williams BW, Byrne PD, Welindt D, Williams MV. Miller’s pyramid and core competency assessment: A study in relationship construct validity. J Contin Educ Health Prof 2016;36(4):295-299. https://doi.org/10.1097/ CEH.0000000000000117 21. Ofoegbu EN, Ozumba BC. Establishment of an office of medical education: Nigeria. Med Educ 2007;41(5):507507. https://doi.org/10.1111/j.1365-2929.2007.02730.x 22. Fahal AH. Medical education in the Sudan: Its strengths and weaknesses. Med Teach 2007;29(9-10):910-914. https://doi.org/10.1080/01421590701812991 23. Albanese MA, Dottl S, Nowacek GA. Offices of research in medical education: Accomplishments and added value contributions. Teach Learn Med 2001;13(4):258-267. https://doi.org/10.1207/S15328015TLM1304_08 24. Kiguli-Malwadde E, Talib ZM, Wohltjen H, et al. Medical education departments: A study of four medical schools in Sub-Saharan Africa. BMC Med Educ 2015;15:109. 2-9. https://doi.org/10.1186/s12909-015-0398-y 25. Christopher D, Harte K, George C. The implementation of tomorrow’s doctors. Med Educ 2002;36(3):282-288. https://doi.org/10.1046/j.1365-2923.2002.01152.x 26. Al-Wardy NM. Medical education units: History, functions, and organisation. Sultan Qaboos Univ Med J 2008;8(2):149-156. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074823/ (accessed 3 September 2017). 27. Pritchard LS. Changing course. Med Educ 2004;38(6):584-586. https://doi.org/10.1111/j.1365-2929.2004.01811.x 28. Kalaniti K, Campbell DM. Simulation-based medical education: Time for a pedagogical shift. Indian Pediatr 2015;52(1):41-45. https://doi.org/10.1007/s13312-015-0565-6 29. Davis MH, Karunathilake I, Harden RM. AMEE Education Guide No. 28: The development and role of departments of medical education. Med Teach 2005;27(8):665-675. https://doi.org/10.1080/01421590500398788 30. Gruppen L. Creating and sustaining centres for medical education research and development. Med Educ 2008;42(2):121-123. https://doi.org/10.1111/j.1365-2923.2007.02931.x 31. Entwistle N. Handbook of Educational Ideas and Practices (Routledge Revivals). Oxon: Taylor & Francis, 2015. 32. Ventola CL. Mobile devices and apps for health care professionals: Uses and benefits. Pharm Ther 2014;39(5): 356-364. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4029126/ (accessed 3 September 2017). 33. Barrow MMJ, Samarasekera DD. Strategies for planning and designing medical curricula and clinical teaching. South East Asian J Med Educ 2010;4(1):2-8. http://seajme.md.chula.ac.th/articleVol4No1/MedEdP1_Mark%20 Barrow.pdf (accessed 3 September 2017).

Accepted 5 October 2017.

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Short Research Report

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

A survey of radiation safety training among South African interventionalists A Rose,1 MB BCh, MMed (Community Health); W I D Rae,2 MB BCh, PhD 1

Department of Community Health, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Department of Medical Physics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Corresponding author: A Rose (roseas@ufs.ac.za)

Background. Ionising radiation is increasingly being used in modern medicine for diagnostic, interventional and therapeutic purposes. There has been an improvement in technology, resulting in lower doses being emitted. However, an increase in the number of procedures has led to a greater cumulative dose for patients and operators, which places them at increased risk of the effects of ionising radiation. Radiation safety training is key to optimising medical practice. Objective. To present the perceptions of South African interventionalists on the radiation safety training they received and to offer insights into the importance of developing and promoting such training programmes for all interventionalists. Methods. In this cross-sectional study, we collected data from interventionalists (N=108) using a structured questionnaire. Results. All groups indicated that radiation exposure in the workplace is important (97.2%). Of the participants, the radiologists received the most training (65.7%). Some participants (44.1%) thought that their radiation safety training was adequate. Most participants (95.4%) indicated that radiation safety should be part of their training curriculum. Few (34.3%) had received instruction on radiation safety when they commenced work. Only 62% had been trained on how to protect patients from ionising radiation exposure. Conclusion. Radiation safety training should be formalised in the curriculum of interventionalistsâ&#x20AC;&#x2122; training programmes, as this will assist in stimulating a culture of radiation protection, which in turn will improve patient safety and improve quality of care. Afr J Health Professions Educ 2018;10(1):10-12. DOI:10.7196/AJHPE.2018.v10i1.981

Interventionalists are highly specialised doctors who undergo rigorous training. The use of ionising radiation is an integral part of their medical practice and potentially poses major occupational health risks, such as skin damage, genetic and chromosomal aberrations, carcinomas and cataract formation.[1] The use of this modality for diagnostic, treatment and interventional procedures has increased substantially, posing greater occupational risks.[2] In medicine, occupational radiation protection is challenging and increased vigilance is required to protect radiation healthcare workers (HCWs).[1] Ionising radiation places patients at risk of developing skin reactions and alopecia, malaise, gastrointestinal problems, damage to heart and lungs, and primary and secondary carcinomas.[3] Patients may receive an increased radiation dose owing to over-investigation, because of the complexity and duration of procedures or poor radiation safety practices by operators.[3] Improved knowledge of radiation safety for patients may assist in reducing these complications and thus improve the quality of care.[4] Specialists require dedicated training in radiation safety, as it effectively reduces radiation risk and optimises radiation safety practices.[5] There is a need to elevate the level of training received by interventional cardiologists to that of interventional radiologists.[6] This may be challenging, as the cardiologistsâ&#x20AC;&#x2122; curriculum already comprises an enormous volume of work, but it is important that professional and regulatory bodies find a way to implement and foster these changes in the interest of interventionalists and their patients.[6]

Developing a culture of learning will assist in developing a culture of radiation protection (CRP), which is essential to lessen radiation exposure. A CRP is a combination of the knowledge, beliefs and practices in an organisation that promotes radiation safety in the workplace.[7] Creating and sustaining a CRP is the responsibility of the catheterisation laboratory team (doctors, nurses and radiographers) and managers.[8] The latter are responsible for ensuring that the equipment is functional and maintained and for providing sufficient and correct personal protective equipment (PPE).[8] A CRP creates awareness of the risks of radiation injury to patients and operators and facilitates improved compliance with PPE use.[7] This culture can be stimulated by including radiation safety training in the formal curriculum of all interventionalists.[9] The objective of this article is to present the findings of the perceptions of South African (SA) interventionalists on the radiation safety training they received and to offer insights into the importance of developing and promoting such training programmes for all interventionalists in SA.

Methods

In this cross-sectional study, we collected data by means of a structured survey. The study forms part of a larger multiple-methods study, which is described elsewhere.[10] The study population consisted of SA radiologists, adult cardiologists and paediatric cardiologists. Data were collected at cardiology and radiology conferences between May 2015 and September 2016 by an electronic survey

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Short Research Report system (EvaSys, UK) (www.evasys.co.uk) and hard copy. The hyperlink to the survey was emailed to delegates at the conferences and workshops and to academic departments in SA. Hard copies of the survey were handed out at the scientific meetings. There was no randomisation and all eligible interventionalists willing to participate were included in the study. The data were captured electronically, exported to Stata version 14 (StataCorp., USA), and a descriptive analysis was done.

Ethical approval

Ethical approval was granted by the Human Research Ethics Committee of the Faculty of Health Sciences, University of the Free State, Bloemfontein, SA (ref. no. ECUFS 44/2015). Participants provided written informed consent, and consent was assumed if participants proceeded with the online survey.

Results

A total of 108 interventionalists completed the survey. Table 1 presents a descriptive analysis of this group, which illustrates their demographic characteristics and the radiation safety training they received.

Discussion

Interventional procedures place patients and operating staff in the catheterisation laboratory at increased risk of adverse health effects owing to radiation exposure.[1,3] Most participants (97.2%) ranked occupational

radiation exposure as an important consideration (Table 1), which suggests that they were aware that ionising radiation is an occupational risk. It is, however, important to explore their understanding of the risk and its sequelae. Despite technological improvements, resulting in equipment emitting lower doses, low-dose radiation may still have detrimental effects on health.[3] Therefore, training in radiation safety is imperative and essential for protecting staff in the radiation workplace.[11] Overall, participants reported receiving low levels (35.2%) of training in radiation safety. Radiologists reported higher levels (65.7%) of training than cardiologists. These results are similar to those of other studies, where radiologists demonstrated higher levels of knowledge of radiation safety.[9] The median duration of time worked for all participants was 10 (interquartile range 5 - 20) years; participants might therefore have had difficulty recalling their training, which might have introduced bias. Even though radiobiology and radiation physics are included in the Part I examination for the Fellowship of the College of Diagnostic Radiologists of South Africa, not all the radiologists reported having received training in radiation safety.[12] It is unclear why, despite their training for the Part I examination, radiologists did not report having received training in radiation safety. It is concerning that there is a difference in training between radiologists and cardiologists, as the interventional procedures performed by these two groups result in similar radiation exposure â&#x20AC;&#x201C; placing them at similar

Table 1. Radiation-safety training among South African interventionalists Demographic characteristics Age, years Median IQR Range Sex, n (%) Male Female Worked, years Median IQR Range Sector, n (%) Public Private Both Perception of occupational radiation exposure, n (%) Important Somewhat important Received radiation safety training, n (%) Training should be part of the curriculum, n (%) Received radiation safety induction on commencing work, n (%) Received at least one talk on radiation safety, n (%) Trained on how to protect patients from radiation, n (%) Trained on how to use X-ray equipment, n (%) Considered training adequate, n (%) IQR = interquartile range.

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Radiologists, n=35

Adult cardiologists, n=41

Paediatric cardiologists, n=32

Total, N=108

43 36 - 49 30 - 60

48 41 - 59 31 - 69

43 39 - 53 32 - 59

44 39 - 53 31 - 69

17 (48.6) 18 (51.4)

37 (90.2) 4 (9.8)

20 (62.5) 12 (37.5)

74 (68.5) 34 (31.5)

11 5 - 16 2 - 32

11 5 - 21 1 - 40

9 5 - 14 1 - 28

10 5 - 20 1 - 40

14 (40.0) 15 (42.9) 6 (17.1)

11 (26.8) 23 (56.1) 7 (17.1)

22 (68.7) 2 (6.3) 8 (25.0)

47 (43.5) 40 (37.1) 21 (19.4)

35 (100) 0 23 (65.7) 34 (97.1) 19 (54.3) 21 (60.0) 28 (80.0) 24 (68.6) n=31 19 (61.3)

39 (95.1) 2 (4.9) 10 (24.4) 39 (95.1) 14 (34.2) 25 (60.9) 25 (60.9) 20 (48.8) n=24 8 (33.3)

31 (96.9) 1 (3.1) 5 (15.6) 30 (93.8) 4 (12.5) 7 (21.9) 14 (43.8) 8 (25.0) n=13 3 (23.1)

105 (97.2) 3 (2.8) 38 (35.2) 103 (95.4) 37 (34.3) 53 (49.1) 67 (62.0) 52 (48.2) N=68 30 (44.1)

Short Research Report risk.[6] It is important that different specialties employing radiation receive dedicated instruction and training in radiation safety to optimise their medical practice.[13] Most participants (95.4%) indicated that it was necessary to include radiation safety in the curriculum. Overall, participants indicated low levels of satisfaction (44.1%) with the level of radiation safety training they had received. The combination of these two factors should encourage the curriculum developers for these two groups to investigate and address this omission, especially for cardiology training.[13] One study indicated that implementation of a training programme resulted in a significant short- and long-term reduction in radiation dose to patients and radiation HCWs.[14] Advocating small behavioural changes among interventionalists reduces radiation during procedures, but requires educating them, especially cardiologists.[15] Encouraging more optimal radiation practices is very difficult and necessitates proactive training strategies.[16] Training in radiation safety greatly improves reduction in radiation dose to patients and operators.[16] Training programmes, however, cannot be a once-off event. In a study by Georges et al.[16] it was found that the duration of the impact of training was up to a maximum of 3 months and then tended to decrease.[16] This suggests that there needs to be continuing reinforcement and training in this field. We suggest that the topic should be part of continuing medical education programmes and incorporated into radiology and cardiology conferences. Training of interventionalists in radiation safety may have two very important consequences. Firstly, it may increase awareness of ionising radiation as an unseen occupational hazard and facilitate utilisation of PPE to mitigate the effects of radiation. This protects an already scarce and highly skilled healthcare workforce. Secondly, radiation HCWs may become more vigilant when considering the dose administered, thus protecting the patient. Patient safety is the keystone of quality care.[4]

Study limitations

This study did not explore participants’ understanding of specific health risks related to ionising radiation. It also did not investigate the participants’ thoughts with regard to the content and depth of a radiation safety curriculum. There may be recall bias from participants in reporting the training they received. It should be investigated why all the radiologists did not report having received training in radiation safety. A culture of radiation protection is discussed in an article linked to this study.[17]

Conclusion

Establishing and maintaining an adequate radiation safety training programme is crucial to instilling and sustaining a culture of radiation protection, which can protect radiation workers and patients and improve the quality of care. Radiation safety training should be part of formal

training programmes and its importance emphasised for it to be effective. Further research is necessary to determine the areas of deficit in radiation safety among interventionalists and how these can be addressed. Acknowledgements. None. Author contributions. AR conceptualised the study, developed the protocol, collected and analysed the data, and wrote the first and final draft of the manuscript. WIDR conceptualised the study and contributed to the final draft of the manuscript. Funding. The PhD from which this study emanated was funded by the South African Medical Research Council (SAMRC) under the SAMRC Clinician Researcher Programme. AR received the Discovery Foundation Scholarship, which funded the data collection of this project. SA Heart (Free State Branch) partially funded data collection for the project. WIDR is a recipient of a National Research Foundation incentive grant. Conflicts of interest. None.

1. Smilowitz NR, Balter S, Weisz G. Occupational hazards of interventional cardiology. Cardiovasc Revasc Med 2013;14(4):223-228. https://doi.org/10.1016/j.carrev.2013.05.002 2. Le Heron J, Padovani R, Smith I, Czarwinski R. Radiation protection of medical staff. Eur J Radiol 2010;76(1):2023. https://doi.org/10.1016/j.ejrad.2010.06.034 3. Stewart F, Akleyev A, Hauer-Jensen M, et al. ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs – threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012;41(1-2):1-322. https://doi.org/10.1016/j.icrp.2012.02.001 4. Mitchell PH. Defining patient safety and quality care. In: Hughes RG, ed. Patient Safety and Quality: An Evidence Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US), 2008. 5. Sheyn DD, Racadio JM, Ying J, Patel MN, Racadio JM, Johnson ND. Efficacy of a radiation safety education initiative in reducing radiation exposure in the pediatric IR suite. Pediatr Radiol 2008;38(6):669-674. https://doi. org/10.1007/s00247-008-0826-9 6. Rehani MM. Training of interventional cardiologists in radiation protection – the IAEA’s initiatives. Int J Cardiol 2007;114(2):256-260. https://doi.org/10.1016/j.ijcard.2005.11.061 7. Fridell K, Ekberg J. Making the invisible visible: A qualitative study of the values, attitudes and norms of radiologists relating to radiation safety. J Radiol Protect 2016;36(2):200-214. https://doi.org/10.1088/09524746/36/2/200 8. Cole P, Hallard R, Broughton J, et al. Developing the radiation protection safety culture in the UK. J Radiol Protect 2014;34(2):469-484. https://doi.org/10.1088/0952-4746/34/2/469 9. Sadigh G, Khan R, Kassin MT, Applegate KE. Radiation safety knowledge and perceptions among residents: A potential improvement opportunity for graduate medical education in the United States. Acad Radiol 2014;21(7):869-878. https://doi.org/10.1016/j.acra.2014.01.016 10. Rose A, Rae W, Chikobvu P, Marais W. A multiple methods approach: Radiation associated cataracts and occupational radiation safety practices in interventionalists in South Africa. J Radiol Protect 2017;2(37):329-339. https://doi.org/ 10.1088/1361-6498/aa5eee 11. Cousins C, Sharp C. Medical interventional procedures – reducing the radiation risks. Clin Radiol 2004;59(6):468473. https://doi.org/10.1016/j.crad.2003.11.014 12. Colleges of Medicine of South Africa. https://www.cmsa.co.za/default.aspx (accessed 13 October 2017). 13. Rose A, Rae WID. Perceptions of radiation safety training among interventionalists in South Africa. Cardiovasc J Afr 2017;28(3):196-200. https://doi.org/10.5830/CVJA-2017-028 14. Kuon E, Weitmann K, Hoffmann W, et al. Multicenter long-term validation of a minicourse in radiation-reducing techniques in the catheterization laboratory. Am J Cardiol 2015;115(3):367-373. https://doi.org/10.1016/j. amjcard.2014.10.043 15. Azpiri-López JR, Assad-Morell JL, González-González JG, et al. Effect of physician training on the X-ray dose delivered during coronary angioplasty. J Invasive Cardiol 2013;25(3):109-113. 16. Georges J, Livarek B, Gibault-Genty G, et al. Reduction of radiation delivered to patients undergoing invasive coronary procedures. Effect of a programme for dose reduction based on radiation-protection training. Arch Cardiovasc Dis 2009;102(12):821-827. https://doi.org/10.1016/j.acvd.2009.09.007 17. Rose A, Uebel K, Rae W. Interventionalist perception on a culture of radiation protection. S Afr J Rad 2018;22(1):a1285. https://doi.org/10.4102/sajr.v22i1.1285

Accepted 24 July 2017.

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Research

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

Physiotherapy clinical education at a South African university V Chetty, PhD; S Maddocks, MPhysio; S Cobbing, PhD; N Pefile, MSc, MedSc (Rehabilitation); T Govender, BPhysio; S Shah, BPhysio; H Kaja, BPhysio; R Chetty, BPhysio; M Naidoo, BPhysio; S Mabika, BPhysio; N Mnguni, BPhysio; T Ngubane, BPhysio; F Mthethwa, BPhysio Discipline of Physiotherapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: V Chetty (chettyve@ukzn.ac.za)

Background. Clinical education for physiotherapists forms a vital part of undergraduate programmes and equips students with competencies to practise autonomously as qualified health practitioners. However, disparities are evident in approaches to clinical education. Objective. To explore the perceptions of physiotherapy students, community-service physiotherapists and physiotherapy clinical supervisors regarding the clinical education framework at a tertiary institution in South Africa in order to understand preparedness of students for practice. Methods. A case study approach with two focus group discussions with students and interviews with community physiotherapists and clinical supervisors was employed. Data were analysed and categorised into key themes and sub-themes. Results. Five themes emerged from triangulation of data from the three groups: preparedness for professional practice, institutional barriers, curriculum disputes, personal factors and recommendations for physiotherapy clinical education. Students felt inadequately prepared owing to a perceived lack of exposure to certain aspects of physiotherapy, while community therapists believed that reflection on the undergraduate programme after qualifying contributed to their adequate preparation. Clinical supervisors supposed that students would benefit from actively engaging with teaching and learning opportunities, and clinical personnel collaboration was seen as key to facilitate a continuum in clinical education from classroom to healthcare setting. Conclusion. Participants reported that the existing curriculum structure may need to be revisited to address various issues, while holistic collaboration between students, supervisors and clinical personnel is imperative to create a cohesive learning environment. Afr J Health Professions Educ 2018;10(1):13-18. DOI:10.7196/AJHPE.2018.v10i1.987

Physiotherapy is a health profession that is focused on the rehabilitation of individuals faced with impairments, activity limitations and/or disabilities that affect daily life. Furthermore, physiotherapists promote quality of life through identification of environmental and social barriers and promotion of health and wellbeing.[1] Becoming a registered physiotherapist in South Africa (SA) requires graduating from an undergraduate training programme at one of eight universities and successfully completing 1 year as a remunerated supervised community-service physiotherapist.[2] The duration of the SA undergraduate physiotherapy programme is 4 years, leading to a Bachelor of Science in Physiotherapy degree.[2] The university where this study took place offers a physiotherapy programme with an intake of ~50 students in the first year. In the second year of undergraduate training, students are exposed to clinical learning platforms, but are merely observers at this level. In the third year, students begin clinical rotations in groups of 6 or 7 for periods of 5 weeks – 4 blocks per year. The clinical blocks cover cardiopulmonary, neurological and neuromuscular conditions and community rehabilitation, including health promotion and awareness. During the third year, students assess and treat patients individually under the supervision of clinical supervisors and physiotherapists employed at clinical sites. Students are subjected to both formative and summative assessments, including bedside clinical examinations at the culmination of each block. The final year of the programme is a reflection of the third-level framework but evolves into specific areas of practice, such as intensive care rehabilitation and orthopaedic mobilisation.[3] Students are also expected to manage patients independently and demonstrate clinical reasoning, including diagnosis and prognosis of patients’ conditions to optimise rehabilitation. During their

final year, students undergo a summative externally moderated examination at the clinical placement areas. Students in their third and fourth years are exposed to clinical practice in primary healthcare settings, as well as various public healthcare contexts, spanning quaternary-, tertiary- and district-level hospitals. These students are supervised and assessed by clinical educators, who are academic staff or university-employed physiotherapy clinicians. They are referred to as clinical supervisors for the purpose of this article. Two or sometimes three clinical supervisors are responsible for clinical training of physiotherapy students per clinical block. Supervisors facilitate group work through case presentations and problem-based learning and use individual bedside teaching as core strategies of learning. There is at least one clinical supervisor per day to supervise the 6 or 7 students per clinical block. Supervision time varies from 1 hour of case presentations with all students to supervising students managing patients for 45 minutes - 1 hour at least once during a block. The nature of clinical supervision is consistent throughout the clinical blocks. The role of clinical supervisors is essential in the co-creation of knowledge and facilitation of learning within the physiotherapy programme.[4] Clinical education is essential to prepare undergraduate physiotherapy students to gain profession-specific knowledge, develop technical skills and become socially and ethically competent to practise independently.[5-8] In SA, these are governed by the universities’ graduate competencies framework. Health science students should demonstrate adeptness in seven key roles, i.e. as practitioner, communicator, collaborator, leader, scholar, health advocate and professional.[9] Although clinical education is fundamental for the preparation of students to practise autonomously, little evidence exists on the approaches to deliver an ideal model for training of the physiotherapy

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Research student.[5] A review of clinical education models was conducted in 2007, which analysed a milieu of models in global contexts.[7] These included the one-educator-to-one-student model, one-educator-to-multiple-students model, multiple-educators-to-one-student model, multiple-educators-tomultiple-students and/or non-discipline-specific-educator model, and finally student-as-educator model. The review found that no model proved to be superior to another and that benefits and inhibitors influencing the various models were used internationally in tertiary institutions.[7] Furthermore, a gap exists regarding a model to guide clinical education in the current SA context and approaches to address discrepancies in tertiary clinical training. This study aimed to explore the views of current students, past students who were in their community-service year of practice, as well as clinical supervisors – to understand the landscape for co-operative construction of the clinical education platform at the tertiary institution of research interest in this study. Another objective was to contribute to the development of an integrated teaching and learning model of clinical education within the current study context to inform further enquiry and have a positive influence on the SA health science education.

Methods

A qualitative explorative case study approach allowed for investigation of the clinical education component of a physiotherapy programme at a tertiary institution in SA.[10] With this approach, real-life phenomena could be studied, as experienced by students, community-service physiotherapists and clinical supervisors in a resource-limited higher education context.[10,11] An holistic single case study with triangulation of data from the students, community physiotherapists and clinical supervisors was used to understand the clinical education experience at the university and its collaborating clinical learning platforms.[11]

Ethical approval

The study was approved by the Humanities and Social Sciences Research Ethics Committee at the University of KwaZulu-Natal in SA (ref. no. HSS/1124/016U). Permission was also obtained from all designated authorities, including the academic leader of the university’s physiotherapy department.

Participant enlistment

The following were recruited through purposive maximum variation sampling: 22 final-year physiotherapy students from a class of 50; 9 commu nity-service physiotherapists from various clinical settings, including rural, urban and semi-rural settings; and 9 of 12 physiotherapy clinical supervisors responsible for clinical education and supervision of students. Maximum variation sampling for the current case study approach allowed for a wide range of views, including current students, communityservice physiotherapists, i.e. physiotherapy students who completed their undergraduate degree at the study setting the previous year, as well as clinical supervisors.[12] All participants signed informed consent forms to participate voluntarily in the study. No incentives were offered. Pseudonyms were used to annotate quotes from participants.

Data collection

Two focus group (n=12 and n=10) discussions were conducted with the final-year students at the institution to allow an open discussion with each

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other and to develop thinking. The focus groups remained open and flexible and allowed researchers who were part of the physiotherapy student body to delve into experiences and develop themes. An independent researcher and registered physiotherapist interviewed the clinical supervisors and community-service therapists using semi-structured interview guides, as it was challenging to co-ordinate focus groups with the professionals in the respective groups (community-service physiotherapists and clinical supervisors). The relevant literature was reviewed and feedback from a pilot interview, as well as discussions with two experts in qualitative research methodology at the university, guided the process. A tape-recorder was used to capture narratives, while verbal nuances were recorded manually. The raw data were transcribed verbatim immediately after discussions and shared with the participants for verification.

Data analysis

Transcribed data were entered into NVivo 9 software (NVivo, USA) and read independently several times by researchers. Two teams of researchers derived themes and sub-themes. Two experts in qualitative methodology assisted in facilitating discussion around data and in attaining consensus among the researchers regarding themes and sub-themes. Methodological rigour was maintained through triangulation of data sources, member checking for veracity, peer debriefing and use of thick, rich descriptions. Furthermore, researcher bias was minimised by interviews conducted by peers, adding valued prompts by means of the data gathering.[11,13]

Results

Five overarching themes, i.e. preparedness for professional practice, institutional barriers, curriculum discrepancies, personal factors and recommendations for physiotherapy clinical education, were identified. Sub-themes were also derived from the triangulated data from the students, community-service physiotherapists and clinical supervisors. Table 1 reflects the data of each group of participants, including age and gender. The community-service therapists worked in environments spanning rural, urban and semi-rural settings. Five supervisors had >5 years of experience, 3 clinical supervisors had 1 - 5 years of experience, and 1 clinical supervisor had >10 years of experience. Table 2 displays the themes and sub-themes that emerged from triangulation of the data.

Themes

1. Preparedness for professional practice and associated sub-themes, as well as perceived lack of graduate attributes for clinical practice, are described in the following narratives, together with illustrative quotes. Some of the final-year students in this study felt unprepared to face clinical practice in their upcoming community-service year and thought that they were not sufficiently equipped to manage patients within certain fields of physiotherapy, such as paediatric care: ‘We do get exposure but not in all areas … other universities cover blocks like paediatrics.’ (Student, Kaitlin) Some students and the majority of the community-service physiotherapists believed that undergraduate clinical training provided a suitable foundation for clinical practice, patient care and clinical reasoning:

Research Table 1. Biographical data and characteristics of participants (N=40) Gender Participants Final-year students Community-service physiotherapists Clinical supervisors

Male 6 3 3

Female 16 6 6

20 - 29 22 9 2

30 - 39 6

Age group, years 40 - 49 -

50 - 59 1

Table 2. Summary of categories and themes Themes Preparedness for professional practice

Institutional barriers

Curriculum discrepancies

Personal factors

Recommendations for physiotherapy clinical education

Sub-themes Perceived unpreparedness in exit year Reflective preparedness for community service Perceived lack of graduate attributes Student/supervision ratio Work overload Time constraints Site barriers Disparity in curriculum design Irrelevant theoretical content Cohesive learning Student/educator relationship Personal perceptions Student engagement Communication breakdown Theoretical bedside approach Improved inclusive educational content Improved curriculum design Communication between stakeholders Collaboration with clinicians

‘ It was a little difficult at first but I adapted quickly, physio knowledge [referring to undergraduate training] serves as a fair foundation.’ (Community-service physiotherapist, Anele) The perceived lack of professional attributes, such as communication, was highlighted in the voices of the clinical supervisors: ‘The dedication and calibre of students have changed and evolved in the past few years; students have a sense of entitlement and don’t communicate properly.’ (Clinical supervisor, Refilwe) 2. Institutional barriers. The quotes below reflect the barriers experienced by participants. The students reported that they were adequately supervised, but could benefit from smaller numbers of students per clinical supervisor: ‘Compared to last year, it is now better to have smaller groups [referring to decreased number of students in blocks from 13 - 14 to 6 - 7] … I feel the smaller the number of students, the easier it is to supervise and I wish we had even fewer ... [giggles].’ (Student, Sandy) Work overload, time constraints and other site barriers posed further challenges to the clinical training platform, as mentioned by students and clinical supervisors: ‘I feel like the qualifieds [physiotherapists at the hospitals] on clinical sites give us all too much work; it is because they have too much work to do.’ (Student, Chris)

‘ Time is always a challenge, there is so much to learn and very little time to teach it all.’ (Clinical supervisor, Angelique) ‘Limited resources at the clinical sites like equipment is always a challenge, also sometimes you go through periods of insufficient patients on site.’ (Clinical supervisor, Oupaman) 3. Curriculum discrepancies are reflected in illustrative quotes from the participants. The disparity in the curriculum design of the undergraduate programme is evident in echoed voices of students: ‘Well, theory-wise I think for us Zulu-speaking students they should change that module to an English module … irrelevant modules covered in first and second year.’ (Student, Melusi) Students indicated that some of the theoretical content taught in the programme was irrelevant: ‘There are some theoretical parts [referring to the basic sciences] that we barely actually do apply!’ (Student, Chante) Cohesive agreement between theory and practical sessions seemed to be something students thought was neglected. They believed that there was a gap between what they were learning in the classroom and what they were expected to apply clinically at the healthcare settings when managing patients: ‘I feel that sometimes they don’t correlate what we learnt in class with what is expected in hospital; I couldn’t apply it at the hospital.’ (Student, Annie)

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Research 4. Personal factors are illustrated by the quotes below. The relationship between student and educator seemed to be ill-defined and posed challenges to clinical education: ‘Students feel we owe it to them to hand over all the information; it is not the norm but there is a trend to ask for things at any time and they don’t want to meet you half way.’ (Clinical supervisor, Chloe) Perceptions, such as favouritism, seemed to be a challenge that faced students and hindered learning: ‘We need to be treated fairly and equally. Supervisors need to stop this habit of having favourites, and level with us all.’ (Student, Thomas) Student engagement as active learners on the teaching platforms seemed to be another inhibitor in optimum clinical education: ‘Students are not active participants of their own learning outcomes.’ (Clinical supervisor, Refilwe) Communication breakdown between stakeholders, e.g. clinical supervisors and clinical placement staff, posed a barrier to optimal learning: ‘We would like the supervisors and the hospital physiotherapists to have the same stories … during exam time we get so confused because of their contradicting ideas.’ (Student, Xolani) 5. Recommendations for physiotherapy clinical education is the final reflection of the study results. A theoretical bedside approach was suggested as a way forward for students to bridge the gap between theory and clinical practice: ‘It will also be nicer if the clinical supervisors would treat patients in front of you at the hospital.’ (Community-service therapist, Nasreen) Students echoed that a more comprehensive and inclusive undergraduate programme, including different aspects of physiotherapy, would benefit them: ‘We need to have a sports block because the whole aspect of us choosing physiotherapy is to have different options when working, and more blocks to touch on paediatrics and strapping should be done in a module as well.’ (Student, Andiswa) Students felt that the curriculum design could be improved by rearranging modules for fluidity, which would have a positive impact on clinical education and patient management: ‘Some of the modules should be rearranged to help you, e.g. isiZulu should be brought into second or even third year to help us communicate better with our patients.’ (Student, Thobile) Students believed that the communication between stakeholders could be improved by tutorials to have a positive impact on clinical education: ‘The lecturers (academic) should give the supervisors (clinical) tutorials about what we are learning so it [clinical education] will fit what we are learning in the classroom.’ (Student, Moses) Clinical supervisors were convinced that collaboration with clinicians on site would improve the clinical education framework: ‘There needs to be buy-in and greater involvement with the clinicians (at placement sites), as they should be more involved in clinical education.’ (Clinical supervisor, Africa)

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Discussion

Clinical education is essential for the training of physiotherapists to prepare them for autonomous practice in their future careers as healthcare professionals. The evidence in a SA context is scarce – insight was gleaned from a broader international framework of the literature regarding various approaches to and perceptions of clinical education for physiotherapy students and their clinical training. It is believed that students learn the technical skills, as well as social and attitudinal competencies, to manage patients in their communities during their clinical education in undergraduate programmes.[5,6] Final-year physiotherapy students who participated in the focus group discussions felt unprepared to manage patients and apprehensive to start their communityservice practice year. According to Roman and Dison,[14] SA universities are currently facing a lack of student preparedness, which is attributed to an array of factors, including the multilingual needs of the students and the large intake of students into university programmes. However, according to Ramli et al.,[15] students experienced anxiety towards initial exposure during clinical placements, but later developed a sense of confidence in their professional competencies. Interviews with community-service therapists revealed that they only experienced retrospectively that the undergraduate training adequately prepared them for community service. Students’ undergraduate education must equip them with skills for continuous reflective practice.[16] Mostert-Wentzel et al.,[17] in an appreciative inquiry into experiences of community-service physiotherapists in SA, advocated for reflection with regard to clinical learning in undergraduate training that could enhance clinical practice. If students were to critically reflect on the clinical education experienced during their placements, this should impact on their learning and the actions that emanate from it, which will contribute to deepened learning.[15] Clinical supervisors need strategies to stimulate reflection on learning at an undergraduate level to enhance clinical education and learning in graduate programmes.[5] Reflective diaries and learning contracts are means used to enhance reflective practice, aid in developing thought and create change in students’ personal learning methodologies.[15,18] Mostert-Wentzel et al.[17] suggested that discussions and presentations could form part of reflections for clinical education. Blended learning and online and face-to-face teaching are also reported to improve reflective skills of physiotherapy students.[16] The healthcare system in SA is faced with resource constraints, which often inhibit the implementation of models of healthcare that address the burden of disease in the country.[19] These constraints include healthcare staff shortages and infrastructural limitations.[20] Similar constraints have hindered teaching and learning as perceived by participants in the study, as they felt that the shortage of staff, time constraints and lack of equipment influenced their clinical learning experience. Congruently, Parry and Brown,[21] in their study set at physiotherapy teaching institutions in the UK, stated that challenges for both teaching and assessment in communication strategies for physiotherapy students were a lack of resources, time, staffing and expertise. Stiller et al.,[8] seeking insight into clinical education models in Australia, agreed that healthcare staff are also faced with patient demands, administration and other clinical duties. Students further emphasised that their large numbers compared with those of clinical supervisors at clinical settings impacted on their learning. They believed that fewer students in clinical placements were preferable, as it improved their learning. A study conducted at the same setting revealed that a large number of students being

Research supervised by a limited number of clinical supervisors posed challenges to clinical feedback and supervision within clinical education platforms.[22] However, a study by Sevenhuysen et al.,[23] comparing traditional clinical education (similar to the context of the current study) with a peer-assisted learning model of allied health science students in Australia, found that although the latter model diminished the clinical supervisors’ workload, students and educators preferred the traditional approach. Participants in this study echoed that the curriculum needs to be reviewed owing to disparities, such as irrelevant content and lack of fluidity in the design. It is imperative for students to transform theory into practice. Ramklass,[22] in her study at the same setting, found that the design influences the delivery and quality of the undergraduate physiotherapy programme. Another health sciences study at the same institute found that harmonious theoretically and clinically based teaching is vital for adequate clinical preparation of undergraduate health professions students.[24] Students in this study agreed that there should be more cohesive learning and fluidity in the curriculum design, which is in keeping with a study involving physiotherapists graduating from the same university, who indicated that the absence of theoretical knowledge prior to clinical practice was perceived as a negative attribute of the programme.[22] Physiotherapy students at a university in the Western Cape, SA, felt adequately prepared for clinical practice, which was attributed to a thorough review and alignment of the physiotherapy curriculum.[25] Health science curricula necessitate review and revision to accommodate the dynamic climate of healthcare in SA.[6] The relationship between all stakeholders in the learning process in clinical education approaches needs to be collaborative to achieve success. The students in the study perceived that favouritism was inhibiting their learning process. Students believed that clinical supervisors were paying more attention to some of their peers, which needs to change for improved learning. Students also believed that communication between stakeholders, i.e. clinical supervisors and hospital clinical staff, was lacking. A study in Ireland on barriers and facilitators to a physiotherapy education approach supported collaboration between all stakeholders in the education framework, which facilitated learning and contributed to adequately prepared students.[26] According to Lo et al.,[27] the partnership and working together of the healthcare student and the clinical supervisor are essential to offer an environment of effective learning of technical skills, core competencies and ethical and social integration into clinical practice. Furthermore, Olsen et al.[28] indicated that clinical supervisors are role models and responsible for the students in clinical placement areas; they are also the main information source for students. There was inconsistency in what was taught in the classroom and what clinical staff at healthcare settings communicated. In a study by De Witt et al.,[29] clinicians involved in education of occupational therapy students felt that they were not adequately prepared to teach undergraduate students and feared judgement by the students. Talberg and Scott[25] conceded that lack of preparedness emerges when what is taught in the classroom does not translate into clinical practice. The ongoing communication between the academic institution and the clinical placement area offers an enabling environment for students’ clinical education.[26] The clinical supervisors in this study were challenged by their perception of students, who they believed were not playing a pivotal active role in their learning and placed gratuitous pressure and demands on the supervisors.

Strohschein et al.[30] stated that both students and educators should engage in an ‘intentional, structured process of changing roles during the course of the clinical education process’, meaning a deliberate change in roles to facilitate understanding and improve learning. They also believed that the core competencies, such as communication, collaboration and reflection, formed an integral part of effective learning in clinical education frameworks. Rowe et al.[16] found that a ‘mutually beneficial’ relationship between students and clinical supervisors should be sought to improve learning. The success of the current education platform, as recommended by participants, hinged on improved teaching strategies, such as more bedside tutorials, improved curriculum design and better communication and collaboration among stakeholders, including clinical site staff and clinical supervisors. In Ernstzen et al.’s[5] article, valuable learning opportunities as perceived by physiotherapy students in clinical settings included demonstration of management of patients, discussion, feedback and assessment (both formative and summative). However, the demonstrations of student-led patient management were more valuable than those that were teacher led, as students believed they were central and actively engaged. This paradigm shift is essential for clinical education as the student takes ‘centre stage’. The student-centred strategy leads to learning by discovery, co-creation of knowledge, and direct and reflective learning.[5] Furthermore, as highlighted in the recommendations, communication is a key competency for graduates. It is not merely fundamental for clinical practice and patient management,[31] but also integral for effective team collaboration and a holistic approach to rehabilitation.[25]

Conclusion

Clinical education frameworks are dependent on stakeholder involvement and collaboration, teaching and learning opportunities experienced by students, as well as culture at the clinical placement area.[5,31] A deeper understanding of how students and educators interpret the clinical education framework is important in the delivery of education and how to improve it to address the needs of a diverse healthcare context.[31,32] This study aimed to understand the perspectives of students, past students who were doing community service at the time of the study and clinical supervisors of a physiotherapy clinical education framework at a university in SA. The study yielded results that support the ongoing review and alignment of the physiotherapy curriculum, as well as improved collaboration between all stakeholders. Moreover, the transformative learning shift needs to be in the forefront, as students move to the focal point of their own learning. In a Lancet[33] article, a commission of 20 professional and academic leaders from various countries rallied together to develop a common vision for health science, leaving the issues of tribalism and national boundaries aside. The collaborators advocated for a generation of graduates who are ‘systems based’, who should influence health systems and have core competencies that are locally driven but have global relevance.[33] The commission also acknowledged that specific institutional and instructional reforms are necessary and could be led by transformative learning.[33] The adoption and shift toward transformative learning in physiotherapy curricula across SA could enhance socialisation of students around values and core competencies, resulting in leaders who are critical engagers and creative thinkers.[33] Further discussions and research are recommended to begin institutional debate on feasible approaches to incorporate transformative learning into our education systems.

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Research Acknowledgements. The authors would like to thank the participants for their time and valuable input with regard to the article. We also thank the participating students for their honest responses and contribution to the study. Author contributions. VC, SM, SC and NP: conceptualised the study and recruited the research students to assist with the project. VC and SM: collected the data together with the students. VC, SM, SC and NP: reviewed, analysed and wrote the article. Funding. None. Conflicts of interest. None. 1. World Confederation for Physical Therapists. http://www.wcpt.org/search/node/role%20of%20physiotherapy (accessed 15 May 2017). 2. Health Professions Council of South Africa. http://www.hpcsa.co.za/PBPhysiotherapy (accessed 15 May 2017). 3. University of KwaZulu-Natal. http://physiotherapy.ukzn.ac.za/Homepage.aspx (accessed 15 May 2017). 4. Moore A, Morris J, Crouch V, Martin M. Evaluation of physiotherapy clinical educational models: Comparing 1: 1, 2: 1 and 3: 1 placements. Physiotherapy 2003;89(8):489-501. https://doi.org/10.1016/S0031-9406(05)60007-7 5. Ernstzen DV, Bitzer E, Grimmer-Somers K. Physiotherapy students’ and clinical teachers’ perceptions of clinical learning opportunities: A case study. Med Teach 2009;(3):e102-e105. https://doi.org/10.1080/01421590802512870 6. Krause MW, Viljoen MJ, Nel MM, Joubert G. Development of a framework with specific reference to exit-level outcomes for the education and training of South African undergraduate physiotherapy students. Health Policy 2006;77(1):37-42. https://doi.org/10.1016/j.healthpol.2005.07.015 7. Lekkas P, Larsen T, Kumar S, et al. No model of clinical education for physiotherapy students is superior to another: A systematic review. Austr J Physio 2007;53(1):19-28. https://doi.org/10.1016/S0004-9514(07)70058-2 8. Stiller K, Lynch E, Phillips AC, Lambert P. Clinical education of physiotherapy students in Australia: Perceptions of current models. Austr J Physio 2004;50(4):243-247. https://doi.org/10.1016/S0004-9514(14)60114-8 9. Govender P, Chetty V, Naidoo D, Pefile N. Integrated decentralized training for health professions education at the University of KwaZulu-Natal, South Africa: Protocol for the I-DecT Project. JMIR Res Protoc 2018;7(1):e19. https://doi.org/10.2196/resprot.7551 10. Aberdeen T, Yin RK. Case study research: Design and methods. Can J Action Res 2013;14(1):69-71. 11. Baxter P, Jack S. Qualitative case study methodology: Study design and implementation for novice researchers. Qual Rep 2008;13(4):544-559. 12. Patton MQ. Qual Res. Online library: John Wiley, 2005. https://doi.org/10.1002/0470013192.bsa514 13. Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract 2000;39(3):124-130. https:// doi.org/10.1207/s15430421tip3903_2 14. Roman NV, Dison A. Relationship between student preparedness, learning experiences and agency: Perspectives from a South African university. Afr J Health Professions Educ 2016;8(1):30-32. https://doi.org/10.7196/AJHPE.2016. v8i1.490 15. Ramli A, Ruslan AS, Sukiman NS. Reflection of physiotherapy students in clinical placement: A qualitative study. Sains Malaysiana 2012;41(6):787-793. 16. Rowe M, Frantz J, Bozalek V. The role of blended learning in the clinical education of healthcare students: A systematic review. Med Teach 2012;34(4):e216-e221. https://doi.org/10.3109/0142159X.2012.642831

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17. Mostert-Wentzel K, Frantz J, van Rooijen AJ. A model for community physiotherapy from the perspective of newly graduated physiotherapists as a guide to curriculum revision. Afr J Health Professions Educ 2013;5(1):19-25. https://doi.org/10.7196/AJHPE.203 18. Ramli A, Joseph L, Lee SW. Learning pathways during clinical placement of physiotherapy students: A Malaysian experience of using learning contracts and reflective diaries. J Educ Eval Health Prof 2013;10:6. https://doi. org/10.3352/jeehp.2013.10.6 19. Chetty V, Hanass-Hancock J. The need for a rehabilitation model to address the disparities of public healthcare for people living with HIV in South Africa: Opinion papers. Afr J Disabil 2015;4(1):1-6. https://doi.org/10.4102/ ajod.v4i1.137 20. Cobbing S, Chetty V, Hanass-Hancock J, Jelsma J, Myezwa H, Nixon SA. The essential role of physiotherapists in providing rehabilitation services to people living with HIV in South Africa. S Afr J Physio 2013;69(1):22-25. https://doi.org/10.4102/sajp.v69i1.368 21. Parry RH, Brown K. Teaching and learning communication skills in physiotherapy: What is done and how should it be done? Physiotherapy 2009;95(4):294-301. https://doi.org/10.1016/j.physio.2009.05.003 22. Ramklass S. The clinical education experience of student-physiotherapists within a transformed model of healthcare. Internet J Allied Health Sci Pract 2013;11(2):4. 23. Sevenhuysen S, Skinner EH, Farlie MK, et al. Educators and students prefer traditional clinical education to a peer-assisted learning model, despite similar student performance outcomes: A randomised trial. J Physio 2014;60(4):209-216. https://doi.org/10.1016/j.jphys.2014.09.004 24. Naidoo D, van Wyk J. Fieldwork practice for learning: Lessons from occupational therapy students and their supervisors. Afr J Health Professions Educ 2016;8(1):37-40. https://doi.org/10.7196/AJHPE.2016.v8i1.536 25. Talberg H, Scott D. Do physiotherapy students perceive that they are adequately prepared to enter clinical practice? An empirical study. Afr J Health Professions Educ 2014;6(1):17-22. https://doi.org/10.7196/AJHPE.219 26. McMahon S, Cusack T, O’Donoghue G. Barriers and facilitators to providing undergraduate physiotherapy clinical education in the primary care setting: A three-round Delphi study. Physiotherapy 2014;100(1):14-19. https://doi.org/10.1016/j.physio.2013.04.006 27. Lo K, Osadnik C, Leonard M, Maloney S. Differences in student and clinician perceptions of clinical competency in undergraduate physiotherapy. NZJ Physio 2015;43(1):11-15. https://doi.org/10.15619/NZJP/43.1.02 28. Olsen NR, Bradley P, Lomborg K, Nortvedt MW. Evidence based practice in clinical physiotherapy education: A qualitative interpretive description. BMC Med Educ 2013;13(1):52. https://doi.org/10.1186/1472-6920-13-52 29. De Witt P, Rothberg A, Bruce J. Clinical education of occupational therapy students: Reluctant clinical educators. S Afr J Occupational Ther 2015;45(3):28-33. https://doi.org/10.17159/2310-3833/2015/v45n3/a6 30. Strohschein J, Hagler P, May L. Assessing the need for change in clinical education practices. Phys Ther 2002;82(2):160-172. https://doi.org/10.1093/ptj/82.2.160 31. Ernstzen DV, Bitzer E, Grimmer-Somers K. Physiotherapy students’ and clinical teachers’ perspectives on best clinical teaching and learning practices: A qualitative study. S Afr J Physio 2010;66(3):25-31. https://doi.org/10.4102/ sajp.v66i3.70 32. Chan DS. Combining qualitative and quantitative methods in assessing hospital learning environments. Int J Nurs Stud 2001;38(4):447-459. https://doi.org/10.1016/S0020-7489(00)00082-1 33. 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

Accepted 29 August 2017.

Research

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

Creating opportunities for interprofessional, community-based education for the undergraduate dental therapy degree in the School of Health Sciences, University of KwaZulu-Natal, South Africa: Academicsâ&#x20AC;&#x2122; perspectives I Moodley, B Dent Ther, MSc (Dent); S Singh, PhD Discipline of Dentistry, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: I Moodley (moodleyil@ukzn.ac.za)

Background. Interprofessional education (IPE) provides opportunities for students from two or more health profession disciplines to learn with, from and about each other, to foster collaborative practice in the future, when health professionals are expected to work in healthcare teams. While there are many documented examples of IPE among student health professionals in the literature, dental therapy student participation in IPE has been excluded. Objectives. To explore the opportunities for dental therapy students to participate in collaborative interprofessional, community-based initiatives by engaging with academics in the School of Health Sciences at the University of KwaZulu-Natal. Methods. This qualitative study used audiotaped interviews and focus-group discussions with a purposively selected sample of academics, and the results were thematically analysed. Results. The academics noted several opportunities for dental therapy students to participate in interprofessional, community-based education on various platforms, including school, primary healthcare and other community-based settings. Barriers that may hamper implementation include finding a common time for IPE in the uniprofessional curricula, matching student numbers and lack of staff support. Conclusion. The study findings revealed that opportunities exist for community-based IPE interventions for dental therapy students. However, both the creation and implementation of interprofessional interventions require individual lecturers to act as drivers across all disciplines. Afr J Health Professions Educ 2018;10(1):19-25. DOI:10.7196/AJHPE.2018.v10i1.974

Health professionalsâ&#x20AC;&#x2122; education is currently undergoing a major transformation, in which community-based and interprofessional education (IPE) are being integrated into curricula, to align student training to meet the needs of the communities they are likely to serve and the health systems within which they will work.[1] IPE is an innovative learning strategy that breaks down the professional silos that commonly exist in training institutions.[2] This strategy provides opportunities for students from two or more health profession disciplines to learn with, from and about each other, or to collaborate to provide promotive, preventive, curative and rehabilitative services to patients, in an attempt to enable students to work effectively in healthcare teams upon graduation.[2,3] There are many documented examples of IPE being practised among student health professionals in various institutions, both in South Africa (SA) and internationally. However, participation by students in the field of dentistry has been minimal or non-existent.[4] Students in the dentistry field include dentists, dental therapists and oral hygienists in training, and their omission from interprofessional learning activities is based on the presumption that oral health is separate from general health,[4] although it is integral to general health and wellbeing.[5] Routine dental examinations can result in the early detection of certain systemic diseases that manifest in the oral cavity, making dental personnel important members of a team that manages the overall health of a patient through screening, diagnosis and referral.[4]

Although highly prevalent, oral diseases are largely preventable, and share common risk factors, including an unhealthy diet, excessive tobacco use and harmful alcohol consumption, with other leading non-communicable diseases (NCDs) such as diabetes, cardiovascular diseases, respiratory diseases and certain forms of cancer.[5,6] Integrating oral health-promotion strategies and programmes with broader programmes in preventing and controlling NCDs can lead to better health outcomes.[7] Therefore, collaborating and networking with other healthcare professionals is essential for dental personnel, and should begin in their training, to develop the skills of collaborative practice and holistic patient management. Moreover, SA, specifically KwaZulu-Natal Province, has a considerable burden of disease, including oral conditions, which impacts on the under-resourced health system.[8] The University of KwaZulu-Natal (UKZN) is responsible for training health professionals in the province, and contributes significantly to a workforce that meets the healthcare needs of communities. This is ensured by producing graduates with the key competencies of being compassionate healthcare workers who communicate well with patients from various cultural backgrounds, being able to collaborate with other health professionals in patient management, and being leaders as agents of change. Undergraduate student health professionals from multiple disciplines can improve the health outcomes of communities through contextualised health-promotion initiatives, by collaborating with each other in an interprofessional team approach.

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Research The discipline of dentistry in the UKZN School of Health Sciences offers a 3-year degree in dental therapy and a 2-year diploma in oral hygiene, which is currently being replaced with a 3-year oral hygiene degree. The scope of practice for a dental therapist is preventive and curative oral healthcare, by means of various procedures such as dental examinations, diagnosis of common oral diseases, scaling and polishing, placement of direct restorations and tooth extractions. The dental therapist is well suited to meet the oral health needs of the population in both the public and private sectors and in urban and rural communities. In the public sector, the dental therapist can contribute significantly to improved oral healthcare in primary healthcare settings through oral health education and promotion, and managing oral diseases. By collaborating with other health professionals, (s)he can contribute to improved overall health outcomes in communities, through joint oral health and general health education and promotion, referrals, responding to treatment requests, teaching people about precautions and early detection of oral and systemic diseases.[4] This collaboration needs to be fostered while the dental therapy student is in training, emphasising the need for IPE. This study aims to explore opportunities for dental therapy students’ participation in collaborative interprofessional, community-based initiatives within the School of Health Sciences, UKZN.

Methods

Research setting and context

The College of Health Sciences at UKZN has four schools: clinical medicine, laboratory medicine and medical sciences, health sciences, and nursing and public health. The School of Health Sciences is made up of eight disciplines: audiology; biokinetics, exercise and leisure sciences; dentistry; occupational therapy; optometry; pharmaceutical sciences; physiotherapy; and speech language pathology. Clinical training in these disciplines occurs at campus clinics and designated off-campus sites, such as the oral and dental training site in a local hospital. Community-based education (CBE) at undergraduate level is a prominent feature across all the disciplines, although levels of participation vary. CBE activities include health awareness programmes, screenings and service delivery under supervision at local primary healthcare centres and hospitals, as well as clinical training at decentralised training sites such as regional and district hospitals. At the decentralised sites, students have an extended stay, providing a continuum of care to patients over a period of 2 - 6 weeks, depending on the requirements of each discipline. Interprofessional community-based activities occur through collaboration between some disciplines, but have thus far excluded the discipline of dentistry.

Research design

This was a qualitative exploratory study in which opportunities for interprofessional community-based initiatives for dental therapy students in the UKZN School of Health Sciences were investigated by engaging with academics involved with CBE. This study was part of a larger research project conducted on CBE in the School of Health Sciences. Ethical approval was obtained from the Humanities and Social Sciences Research Ethics Committee, UKZN (ref. no. HSS/1060/015D).

Participants

The researcher used a purposive sampling method to select the study sample of academics, who were selected for their expert opinions. They included

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the College Dean of Teaching and Learning, the school’s Academic Leader: Teaching and Learning, an academic from Family Medicine/Rural Medicine who is involved in the community-based training of medical students and an academic from the discipline of dentistry who is the head of the Professional Board for Dental Therapists and Oral Hygienists in the Health Professions Council of SA. An email invitation was sent to each person to request their participation in the study, by interview. In addition, emails were sent to the academic leaders of each of the eight health sciences programmes, requesting that they nominate one academic currently involved with CBE to participate in a focus-group discussion. Individual emails were sent to the nominated academics requesting their participation. Thus a total of twelve respondents (A1 - A12) agreed to participate in the study (Table 1). All provided written informed consent.

Data collection

The data were collected using both face-to-face individual interviews lasting ~30 minutes, and focus-group discussions. The researcher conducted interviews with the dean and academic leader to gain a deeper understanding of how interprofessional CBE could be implemented within the school, using a set of mainly open-ended questions to elicit qualitative information. The questions related to the policies and procedures for implementing interprofessional CBE, associated support and mechanisms and funding for interprofessional projects. An interview was held with an academic from the Department of Family Medicine to learn how CBE was conducted in other schools within the College of Health Sciences. The researcher conducted the final interview with the academic who heads the Professional Board for Dental Therapy and Oral Hygiene on the HPCSA to gain insight into the HPCSA guidelines regarding interprofessional training for dental therapy. These four interviews were scheduled at the interviewees’ convenience. In addition, the researcher facilitated two focus-group discussions with the academics representing each of the eight disciplines, with four participants in each group, as all academics could not avail themselves at once. The researcher developed a set of questions on participants’ views regarding interprofessional CBE to guide the focus-group discussions. Sample questions included: ‘What are some of the interdisciplinary collaborative activities that you are aware of that are being conducted within the School of Health Sciences?’ ‘What are the opportunities for dental therapy students working collaboratively with other student health professionals to enhance student training within the school?’ and ‘What are the possible barriers perceived to this collaboration?’ The interviews and focus-group discussions were audiotaped, and a research assistant transcribed them verbatim and then edited the language. Table 1. Study population Participant A1 A2 A3 A4 A5-A12

Role in academia Dean of Teaching and Learning in College Academic Leader: Teaching and Learning in School Academic from Family Medicine HPCSA representative Focus-group participants from School of Health Sciences

HPCSA = Health Professions Council of South Africa.

Research method Interview Interview Interview Interview Two focus groups

Research The researcher engaged the services of a research consultant to assist with the data analysis process. Data coding was done by both the researcher and the research consultant to identify particular features of the data, which were then sorted, allowing themes and subthemes to emerge from the respondents’ statements, in accordance with Braun and Clarke’s guide to thematic analysis.[9] Credibility is a form of internal validity in qualitative research that establishes whether the research findings are genuine and are indeed a true reflection of the participants’ original views.[10] In this study, credibility was established through the use of varied research methods, namely interviews and focus-group discussions, to collect the data. Three of the interviewees (A1, A2 and A3) were asked the same questions, while A4 was asked about the HPCSA guidelines, and A5 - A12 were asked questions about opportunities for and possible barriers to IPE implementation. Credibility was further established through peer debriefing, which was undertaken by another member of the research team, who reviewed the data collection methods and processes, transcripts and data analysis procedures, and provided guidance to enhance the quality of the research findings.[10] Transferability relates to external validity in qualitative research, which determines the degree to which the research findings can be transferred to other contexts and other respondents.[10] This was facilitated through the use of purposive sampling and by providing a thick description of the context of the enquiry.[10] Transferability was further enhanced by comparing the research findings with the current literature. Dependability is used to determine whether the same research findings would be achieved consistently if the same participants had been used in the same context.[10] This was achieved through the use of member checks, where the analysed data were sent to a few participants to evaluate the interpretations made by the researcher. Dependability was further enhanced by both the researcher and the research consultant, as a co-coder, analysing the same data and comparing their results. Establishing confirmability means checking that the findings are derived solely from data from participants, and not just made up by the researcher.[10] This was established through using direct quotations of the interviewees’ actual dialogue. Participant confidentiality and anonymity were maintained through the use of codenames to protect the identity of each participant (A1 - A12).

Results

Theme 1: Implementing IPE

Under this theme, three issues arose: the need for IPE; how IPE should be implemented; and when IPE should be implemented. The need for IPE implementation The focus group participants reported that they only knew of one interprofessional collaboration within the school, which involved occupational therapy, audiology, speech language pathology, physiotherapy and biokinetics. This project was initiated through a collaboration of academics from the respective disciplines. Given this context, all respondents agreed that there was a definite need for interdisciplinary education in the school (Table 2). How IPE implementation should occur Some of the respondents’ ideas on how IPE should be implemented are given in Table 3. When IPE should be implemented The academics believed that IPE should have a strategic entry point, as illustrated by the quote: ‘I think level one; if you do it as early as possible, then students get to know and to learn.’ (A2)

Theme 2: Benefits of IPE

Respondents from the focus group recognised the value of different disciplines working together. The academics stated that IPE not only exposes students to the knowledge and skills of their own profession, but also those of others, and that by understanding the scope of practice of other professionals, they could learn to refer patients appropriately in the future (Table 4).

Theme 3: Opportunities for dental therapy student participation in IPE The respondents indicated that there were many opportunities for dental student participation in CBE projects, including integrating oral health into general health-promotion strategies in schools and at primary healthcare centres (Table 5).

Theme 4: Barriers to collaboration in implementing IPE

Academics noted a number of barriers to implementing IPE (Table 6).

Based on the responses of the interviewees, and the focus group discussions, four main themes emerged from the data analysis process: implementing IPE; the benefits of IPE; opportunities for dental therapy students’ participation; and barriers to implementation.

Discussion

This section discusses the findings for each of the four themes: implementing IPE, benefits of collaboration, opportunities for dental therapy students’ participation and barriers to implementing IPE.

Table 2. The need for IPE implementation in the School of Health Sciences Subtheme Inclusive planning for service-based learning Student training aligned to graduate competency Learning as contextualised in real-world settings

Participant’s response ‘I think that there is a need for a definite school strategy to come to the fore.’ (A2) ‘If we want to work in inter-, multi- or transdisciplinary teams later, we need to train in that, you need to have experiences as part of your training as how you work so you get the skills.’ (A3) ‘There is a demand out there and sometimes you are left alone to manage an array of conditions of patients and sometimes there [are] no occupational therapists, for instance. I feel we need to do enough to be able to do the basics or refer at the right point in time.’ (A11)

IPE = interprofessional education.

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Research Table 3. How IPE implementation should occur Idea Integration into existing timetables

Mobile services

Interdisciplinary service delivery on campus

Response ‘I think in health sciences it is very easy to integrate it because we already do clinical placements in all of our programmes. It is not like we have to go and reinvent, getting placements fitting it into the timetable, the structure is there, we basically have it.’ (A1) ‘The ideal would be to have a mobile clinic or a clinic unit where students are actually able to rotate with the patient. The patient walks in, is assessed in an assessment room by a number of practitioners at the same time, so you will have for example your speech and hearing person, eye specialists, your dental person all assessing the patient in the presence of each other and thereafter referring the patient to the specialist discipline that the patient requires.’ (A4) ‘Having an interdisciplinary clinic on campus. We can have a clinic where we all have sessions on a Friday from 08h00 to 13h00 where each discipline is represented. A patient can go through a system having being exposed to the different disciplines in one healthcare setting. That becomes our own campus training model and when they go out there they know how to work together.’ (A9)

IPE = interprofessional education.

Table 4. Benefits of IPE Benefit Peer-assisted learning

Knowledge of referral patterns Access to healthcare Acquisition of non-technical skills

Response ‘The students learn so much from each other, about each other and about the professions and that is a model for how they are going to be working out there.’ (A5) ‘Sharing of knowledge and skills and also they start to treat the patients as a whole, not in parts.’ (A6) ‘Students are aware of the capabilities of the tasks of the scopes of practice of other types of practitioners so that they are able to refer patients and that actually leads to the holistic treatment of patients.’ (A4) ‘It will contribute immensely to community upliftment – this will improve access to different aspects of healthcare that they were not introduced to previously.’ (A8) ‘Sharing of resources.’ (A6) ‘Problem-solving is much better with the team.’ (A6)

IPE = interprofessional education.

Table 5. Opportunities for dental therapy student participation in IPE Subtheme Integrating oral health into general health

Joining existing CBE programmes Student-initiated IPE projects Participation in school programmes

Health education and promotion activities

Being part of a rehabilitation team

Response ‘Oral health is really very well placed. It actually fits in very well with the primary healthcare, re-engineering primary healthcare and community-based training because especially if it is primary care and preventative and promotion with the school health programme, it actually fits in very well, so it resonates with the national health insurance.’ (A1) ‘Dental therapy can definitely play an important role as I have noticed a lot of children have dental problems, but we see you as a consultant for education events, not on an ongoing basis.’ (A8) ‘It allows for student networking – the students do the inviting. They are the agents of action. They analysed the need and approached the various disciplines to send their students.’ (A8) ‘The school-based team, the dental therapy students could easily come in really effectively with the speech and audio students. It is about looking at where we can come together.’ (A5) ‘Going to a school, working with younger kids and saying we are looking at screening, we can do vision, oral and eye maintenance together. We can look at what services are needed and then manage it so it does not become too overwhelming for patients. If we had projects like this it would be really good. We could also educate teachers on how to pick up on hearing loss and tooth problems.’ (A6) ‘The clinic sites that we go to, we go into the queues, while the moms are there for the immunisation for their babies, go through these are the risk factors, we give them pamphlets. You could do that in their space. It is a captive audience there; basically they do not want to leave the queues to come for the actual testing. We say to students, they make these huge posters and they go and stand in the front, while you are waiting, nobody has to move.’ (A6). ‘They also have support groups and they put people together either with different disabilities or stroke groups. So it is beyond the prevention and promotion, it is also towards development, collaboration.’ (A6) ‘Rehab and long term, at the moment we are seeing a lot of stroke patients, there’s pooling of food, poor dentition, etc., so there is a role for dental therapy.’ (A8)

IPE = interprofessional education.

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Research Table 6. Barriers to implementation of IPE Theme Silo teaching

Mismatch in student numbers Non-compliance of staff

Lack of academic transformation

Community acceptance

Response ‘There is no overall curriculum design that allows you to co-ordinate time when students are able to spend time together. Some disciplines have this block system of 2 weeks and others blocks of 5 weeks and other blocks of 6 weeks so the timing of us all going together to do [an] activity, which would need to be continuous over time, does not fit into every curriculum.’ (A3) ‘If we have 400 medical students and we want every single one of them to have a meaningful experience with a physio, OT, speech therapist, the dentist but you have only got 30 dental therapists. How do you match the numbers?’ (A3) ‘A lot of people are just happy to sit in their offices and keep doing what they have been doing for the past 15 -2 0 years, because they do not see the value. To them it is just a complication, everything is working. We have been doing it this way and it is working, now why are you coming to change things?’ (A9) ‘It is like you want to protect your own territory, you do not realise you can learn from each other and that there is so much growth. We need to transform … it has been a culture of this university that everybody stays in their silos, we need to start working together. (A11) ‘Suddenly they see this team working but they are used to seeing the doctor on their own. It causes a lot of mistrust.’ (A6)

IPE = interprofessional education; OT = occupational therapy.

Theme 1: Implementing IPE

Given the context of needing to produce more socially accountable and relevant healthcare workers, the participants indicated their support for disciplines to create interprofessional learning opportunities for students. The experience of working together with other student health professionals while in training will prepare them for more effective collaborative practice in response to health needs when they graduate. Such initiatives are expected to be driven by interested academics from various disciplines, with no formal mandates from the School of Health Sciences to ensure that this takes place as a learning opportunity. The current IPE project was initiated by lecturers who are drivers in their disciplines, being motivated to transform health professionals’ education and ensure that their students are equipped for various work environments. These lecturers serve as bottom-up drivers for change, having identified a need to make their teaching relevant, which should be noted by management structures that give direction in preparing the school’s graduates. Drivers may be either top-down or bottom-up.[11] Top-down drivers refers to people with the highest rank in an organisational structure directing the change. This includes leaders at universities, such as deans. Bottom-up drivers are interested academics from across multiple disciplines engaged in co-operative creating, planning and implementation to bring about transformation.[11] In the literature, Treadwell and Havenga[12] also note that in the absence of top-down drivers for the implementation of IPE, lecturers interested in transforming health professionals’ education must serve as bottom-up drivers for change. Moreover, documented examples exist where students have identified the need to create collaborative interprofessional learning environments for themselves, having recognised that this was lacking in their education.[13] The study showed that academics had a number of ideas of how IPE could be implemented in the school, one being to integrate IPE into the current curriculum and time-tables. However, integrating IPE into an existing curriculum can be challenging with the selection of disciplines to collaborate with being a complex process.[12] Purden et al.[14] in Treadwell note the complexities of such initiatives, and advocate the collaboration of not more than four disciplines.[12] Academics believe that IPE should be implemented early in the academic programme. This is supported by VanderWielden,[13] who recommends exposing students to IPE early in their education and training, as it offers

increased opportunities for student interaction and collaboration with other emerging health professionals. Its early introduction is recommended as it takes a long time to develop the necessary skills and professional competence and to learn how to work with each other, and reap the benefits of a team approach.

Theme 2: Benefits of collaboration

The respondents reported that there were many advantages to IPE, including the fact that it exposes students to the knowledge and skills not only of their own profession, but other professions too. The respondents stated that this fosters mutual respect, trust and appreciation for other health professionals, and reduces stereotyping and assumptions about others’ roles. The benefits of IPE, such as creating learning opportunities for student health professionals to acquire non-technical skills, teamwork, leadership and social accountability, are well documented in the litera ture.[12-14] Another benefit is ensuring continuous, reliable and integrated care for patients.[13]

Theme 3: Opportunities for dental therapy students’ participation According to the academics in the study, there are many IPE opportunities for dental therapy students. Those involved in the existing interprofessional project were willing to allow dental therapy students to join their project for health education activities, where they could contribute significantly in terms of oral health education for children in the community, as well as offer preventive measures such as fissure sealants and tooth-brushing programmes. This can be seen as an opportunity to screen children for dental problems, offer advice and refer them to the nearest clinic for the management of serious oral conditions. In situations where ‘students are doing the inviting’, dental therapy students could become proactive and liaise with students from other disciplines involved with the project, and also become ‘agents of action’. This is supported by the literature, which draws attention to student-led IPE programmes among student health professionals in the USA, where they recognised interprofessional training as a valuable, but missing, learning strategy in their education.[13] This fostered networking, which is a key component of interprofessional collaboration and developing relationships

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Research that could benefit current education and future patient care.[13] The literature shows that because oral diseases and other NCDs share common risk factors, integrating oral health promotion strategies and programmes with programmes in the prevention and control of NCDs can lead to better health outcomes.[8] This can be implemented using the settings approach. The settings approach The settings approach used in health-promotion initiatives creates opportunities to address relevant health issues in the contexts in which people live, work and play.[15] This approach is widely advocated and yields considerable success, as it organises health-promotion interventions to target specific health problems relevant to specific communities.[15] In this study, the respondents agreed that this approach can be used for collaborative initiatives, and identified two relevant settings – the school and the primary healthcare setting. School setting: The academics in the focus groups suggested that dental therapy students could fit into an interprofessional team that could go to schools where joint oral health and health education programmes, health promotion and screenings could be conducted. Such activities conducted in the school setting have been identified as the most creative and cost-effective way to improve general health, oral health and quality of life.[16] Reddy and Singh[17] noted an increased awareness among learners and educators of the importance of daily tooth brushing and adopting the correct tooth-brushing techniques following oral health education interventions conducted in schools, especially in rural areas. It was further noted that following oral health promotion interventions, learners realised the importance of correct eating habits that could inform their choice of purchases from tuck shops and vendors.[17] Primary healthcare setting: The academics cited primary healthcare settings as another opportunity for interprofessional collaboration for combined oral health and general health promotion initiatives. These could take the form of health education talks, as suggested by the academics, while patients are waiting to be treated. Dental therapy students working together with other health professional students would foster the integration of oral health into general health more effectively, and improve oral healthcare in communities.[18] Treadwell and Havenga[12] have noted that setting the scene and creating the situation is crucial in the actual learning that takes place. Thus, by using the settings approach, students would be exposed to real world settings in which they learn to contextualise, design and implement promotion inventions within resource and funding constraints, this being different from when they will do so at the ideal training sites of their institution. The team approach for rehabilitation Besides collaborating in prevention and promotion activities, opportunities also exist for dental therapy students to participate collaboratively with other health professional students in the rehabilitation of patients with physical disabilities, and stroke patients. A stroke can have major effects on oral and facial soft tissues, and can affect simple oral functions such as chewing, drinking and swallowing.[19] In addition, moving the tongue towards the affected side results in food pooling in that side of the mouth and reduces oral clearance, which increases the risk of dental caries, periodontal diseases and halitosis.[19] Moreover, medications used to treat stroke patients can result in xerostomia (dry mouth), which further increases the

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risk of dental caries.[19] Oral healthcare is therefore important for stroke patients, but is often overlooked during the rehabilitation phase. The team that manages a stroke patient usually consists of physiotherapists, occupational therapists and speech language therapists, with dental personnel not included. In order for changes to occur in the healthcare workplace regarding professional collaboration, transformation must occur at the level of training. Student health professionals from these disciplines, together with dental therapy students, should be given learning opportunities to work together in the rehabilitation of stroke patients. This could lead to better health outcomes for the patient, as well as encouraging the general inclusion of dental therapists in the rehabilitation team. In a systematic review of strategies used for IPE activities, it was observed that the most common strategy used by universities was holding small group discussions, followed by case- or problem-based learning, clinical teaching or direct interaction with patients, simulations, community-based education projects and e-learning.[20] It is clear from the focus-group discussions that there are diverse interprofessional learning opportunities for dental therapy students. These opportunities include joint oral and general health education and promotion activities, screening programmes, diagnosis and referral of patients and rehabilitating patients with stroke and physical disabilities. These opportunities resonate with the principles of primary healthcare, namely prevention, promotion, curative care and rehabilitation, thus establishing a link between IPE and PHC and providing the most appropriate mode for facilitating IPE for dental therapy students.

Theme 4: Barriers to IPE

The main barriers to IPE identified in this study were finding a common time for the students from the different disciplines to participate in IPE activities, matching the numbers of students and a lack of staff co-operation. Abu-Rish et al.,[20] in a systematic review of IPE, also reported similar barriers across 65 studies, such as scheduling a common time for IPE implementation, difficulties in matching numbers of students with similar backgrounds, skills and levels of clinical knowledge, funding, and staff and leadership buy-in. To overcome some of the barriers experienced at UKZN, the academics made the following recommendations: ‘We can start by aligning the sites, opening up communication and start talking to each other.’ (A11) ‘There is huge opportunity to sit and develop either a common module or say these are going to be the common times for all of us even if you keep your own separate modules.’ (A5) ‘You need a phased-in approach to implement such a programme. Just getting the buy-in from everybody that will be involved at every stage in the academic progress.’ (A11) ‘We should bring innovation and change and ourselves be trained in the very same field. We do not know it at all so we should be open to get more knowledge about what is happening elsewhere.’ (A10) Getting the co-operation of staff is challenging; however, Treadwell and Havenga[12] recommend that staff engage in collaborative discussions to develop a shared understanding of the purpose and goals of IPE, to bring about changes in thinking and acceptance.

The way forward

The study findings indicate that dental therapy students are well suited

Research to collaborate with those from the other disciplines. The IPE strategy best suited for their inclusion is engaging in community-based disease prevention and health-promotion interventions, as oral health is related to general health and wellbeing. As a suggestion, it may be a good idea to start a collaboration with one other discipline initially, by integrating oral health promotion into general health-promotion programmes, which can be presented together in primary healthcare settings or school settings. Once the basic logistics have been addressed, other disciplines can be incorporated, depending on how the dental therapy student participation integrates with their curricula and clinical placements. Most of the disciplines in the UKZN School of Health Sciences send students to decentralised sites for work experience, which is an untapped opportunity for student health professionals to engage with each other, network, collaborate and conduct contextualised health-promotion interventions with patients throughout the hospital while patients are waiting to be attended to. A programme could be devised whereby the students start off their day by working collaboratively, after which they work in their respective departments attending to their patients. IPE is an effective pedagogical approach that allows health professions students to gain a better understanding of the roles of other professions, as well as collaborative skills.[21] Universities have an important role to play in creating such learning opportunities, their implementation requiring motivated drivers of change who can initiate this process of transformation. In this study, it was noted that academics from the various disciplines were the drivers in creating and implementing IPE interventions. Academics should embrace this opportunity to meet, collaborate and plan IPE activities for student health professionals. However, successful implementation requires more than just drivers – it requires supportive leadership, committed academics and student compliance.

Study limitations

It is acknowledged that this study was limited to a single university, making the findings and their context limited in their generalisability. More research is therefore required at other universities in SA that train dentistry, dental therapy and oral hygiene students, to obtain a better understanding of how IPE opportunities could be created and incorporated into their programmes.

Conclusion

The study findings revealed that opportunities do exist for interprofessional community-based education for dental therapy students. Using the settings approach, the Discipline of Dentistry undergraduates, in collaboration with other student health professionals, can conduct health-promotion interventions that are contextualised for specific communities, depending on their needs and the available resources, in school, primary healthcare and other community-based settings. Using a team approach, they can be included in student healthcare teams that are involved with screening, diagnosis and referral systems, as well as in rehabilitating patients. However,

the creation of interprofessional interventions requires individual lecturers from the various disciplines to act as drivers in consultation with each other, with support from programme managers to support curriculum changes and resource allocations. To ensure that the students are equipped to participate in team collaborations once they enter the work environment, the School also needs to support and motivate for such collaborations during training. Acknowledgements. None. Author contributions. IM was responsible for data collection, data analysis and conceptualisation. SS was responsible for refining the methodology and overseeing the write-up. Funding. None. Conflicts of interest. None. 1. Frenk J, Lincoln C, Zulfiqar A, 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(11)(60492) 2. World Health Organization. Report on a WHO study group on multiprofessional education of health personnel: The team approach. Technical report series 769. Geneva: WHO, 1988. http://apps.who.int/iris/ handle/10665/37411 (accessed 10 September 2014). 3. Barr H, Koppel I, Reeves S, et al. Effective interprofessional education: Argument, assumption and evidence. Oxford: Blackwell Publishing, 2005. 4. Wilder RS, O’Donnell JA, Barry JM et al. Is dentistry at risk? A case for interprofessional education. J Dental Educ 2008;72(11):1231-1237. 5. Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Geneva: World Health Organization, 2003. 6. Sheiham A, Watt R. The common risk factor approach: A rational basis for promoting oral health. Community Dent Oral Epidemiol 2000;28(6):399-406. https:/doi.org/10.1034/j.1600-05 28,2000.028006399.x 7. Global Action Plan for the Prevention and Control of Non-communicable Diseases. 2013-2020. Geneva: World Health Organization, 2013. www.who.int/iris/bitstream/10665/943384/1/9789241506236 (accessed 4 September 2014). 8. Department of Health, South Africa. Annual Health Report 2013/2014. Pretoria: NDoH, 2014. 9. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 10. Anney, VN. Ensuring the quality of the findings of qualitative research: Looking at trustworthiness criteria. Journal of Emerging Trends in Educational Research and Policy Studies 2014;5(2):272-281. 11. VanderWielen LM, Do EK, Diallo HI et al. Interprofessional collaboration led by health professional students: A case study of the Inter Health Professional Alliance of Virginia Commonwealth University. J Res Interprof Pract Educ 2014;3(3):1-13. https://doi.org/10.22230/jripe.2014v3n3a132 12. Treadwell I, Havenga HS. Ten key elements for implementing interprofessional learning in clinical simulations. Afr J Health Professions Educ 2013;5(2):80-83. https://doi.org/10.7196/ajhpe.233 13. VanderWielen L, Enurah A, Osburn I. The development of student-led interprofessional education and collaboration. J Interprof Care 2013;(0):1-2. https://doi.org/10.3109/13561820.2013.790882 14. Purden M, Fletscher D, Ezer H, et al. The McGill Educational Initiative on Interprofessional Collaboration: Partnerships for patient and family-centred practice.http://wwwinterprofessionalcare.mcgill.ca/projectoverview. htm (accessed 21 March 2018). 15. Poland B, Krupa G, McCall D. Settings for health promotion: An analytic framework to guide interventions design and implementation. Health Promotion Pract 2009;10(4):505-516. https://doi.org/10.1177/1524839909341025 16. Petersen P. Challenges to improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Internat Dental J 2004;54(S6):S329-S343. https://doi.org/10.1111/j.1875-595x.2004. tb00009.x 17. Reddy M, Singh S. The promotion of oral health in health-promoting schools in KwaZulu-Natal, South Africa. S Afr J Child Health 2017;11(1):16-20. https://doi.org/10.7196/SAJCH.2017.v11i1.1132 18. Rhoda A, Lattoe N, Smithdorf G, et al. Facilitating community-based interprofessional education and collaborative practice in a health science faculty: Student perceptions and experiences. Afr J Health Professions Educ 2016;8(S2):S225-S228. 19. Fatahzadeh M, Glick M. Stroke: Epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management. Oral Surg Oral Med Oral Pathol Oral Radiol 2006;102(2):180-191. https:// doi.org/10.1016/j.tripleo.2005.07.031 20. Abu-Rish E, Kim S, Choe L, et al. Current trends in interprofessional education of health sciences students: A literature review. J Interprof Care 2012;26(6):444-451. https://doi.org/10.3109/13561820.2012.715604 21. Hammick M, Freeth D, Koppel I, et al. A best evidence systematic review of interprofessional education: BEME Guide No. 9. Med Teach 2007;29(8):735-751. https://doi.org/10.1080/01421590701682576

Accepted 15 August 2017.

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Research

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

Health education on diabetes at a South African national science festival M Mhlongo,1 BPharm; P Marara,1 BPharm; K Bradshaw,2 PhD; S C Srinivas,1 PhD, PGDHE 1

Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa

Department of Computer Science, Rhodes University, Grahamstown, South Africa

Corresponding author: S C Srinivas (s.srinivas@ru.ac.za)

Background. Diabetes is one of the non-communicable diseases with a major negative impact on the health and development of South Africans. Empowering the populationâ&#x20AC;&#x2122;s understanding of the condition, with health-literacy appropriate approaches, is one of the interventions that allows discussions around the prevention of diabetes. Objective. To determine the effects of a health education programme on increasing knowledge about diabetes and encouraging preventive measures. Method. A public health education exhibition was held by a pharmacy student at a national science festival. It incorporated presentations, posters, health models, word-search games, information leaflets and a computer-based quiz consisting of pre- and post-intervention questions. Results. Junior and senior school learners participated in the computer-based quiz. Results from the junior school pre-intervention phase showed that learners had a fair prior knowledge of diabetes, with an overall score of 52.8%. Improvement in their overall mean score at the 5% significance level was noted (p=0.020). There was a significant difference in the mean score after the intervention at the 1% level (government schools: 65.5 (standard error (SE) 3.1)%, independent schools: 45.9 (6.2)%; p=0.006). Of the senior learners 53.7% (n=137) indicated that they use computers at school, while 118 (46.3%) did not have access to computers. The improvement in overall knowledge of the senior participants after the intervention was significant at the 0.1% level (p<0.001). Conclusion. The health education offered by the pharmacy student's project was interactive and used an interdisciplinary approach to improve health literacy and raise awareness of diabetes. This is a tested intervention that may be adopted for improving health literacy among schoolchildren. Afr J Health Professions Educ 2018;10(1):26-30. DOI:10.7196/AJHPE.2018.v10i1.887

Non-communicable diseases (NCDs) are the leading cause of death worldwide. Although NCDs are on the rise in both developed and developing countries, they affect low- and middle-income countries (LMICs) inordinately.[1] Evidence shows that NCDs continue to rise owing to the prevalence of unhealthy diets, excessive alcohol consumption, smoking and lack of physical activity.[2,3] Such behavioural and lifestyle risk factors can be addressed by increasing primary prevention, public awareness and understanding of NCDs.[4] Health education initiatives and improved health literacy have been shown to be important to improve primary prevention and reduce NCD-related disparities in LMICs.[5] According to the World Health Organization (WHO), diabetes contributes 6% to the mortality rate in South Africa (SA).[6] The International Diabetes Federation (IDF) projects that these statistics will double by 2040.[7] According to the IDF, SA reported 2.28 million cases of diabetes in 2015.[7] This has a negative effect on the health status of SA citizens, given that SA has moved to a quadruple burden of disease according to the Statistics South Africa report.[8] Diabetes is a significant contributor to this burden[9,10] and, with other NCDs, has serious financial implications, particularly on the national government and people of productive age (15 - 64 years).[10,11] Sustainable Development Goal 3 and health education are important tools to achieve sustainable health development in LMICs.[12] The role of healthcare professionals in empowering the public with regard to health matters is vital.[13,14] Pharmacists play an important role in public health, and hands-on health promotion training is therefore

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essential for pharmacy students.[10] The focal point of competency-based training is to improve pharmacistsâ&#x20AC;&#x2122; knowledge and communication skills with regard to NCDs such as diabetes, so that tailor-made and culturally appropriate information is conveyed to patients and the general public.[10] Healthcare empowerment is key to the prevention of diabetes[15,16] and should be implemented by an interdisciplinary team. It provides an effective means of conducting public health education, as it allows the use of technology-based interventions to positively influence health behaviour outcomes.[17] Healthcare empowerment can be achieved by health education, and it is a vital rudimentary intervention strategy in which learning goals and community service are combined in ways that allow both the student and community to benefit.[18,19] Health education outside the classroom facilitates meaningful learning by enabling pharmacy students to transpose[20] course content into real-life scenarios, which may be difficult to achieve in any other way for the analysis and understanding of their experience with the community.[21] This article reports on the effect of a pharmacy student-developed public health education exhibit at a national science festival (NSF) on the understanding of diabetes, its causes and prevention, among a group of school learner attendees.

Method

Research design

A descriptive cross-sectional study was conducted. Quantitative data were collected pre- and post-intervention via a computer-based quiz.

Research Research procedure

Pilot study The pharmacy student first conducted a pilot test using a quiz for senior learners (grade 8 - 12) and one for junior learners (grade 1 - 7). Learners from a mathematics and science club for disadvantaged local schools in the Eastern Cape assisted during this phase. Names of the participants were not collected to preserve anonymity and confidentiality. Participants provided feedback for acceptability of the quiz on diabetes. A presentation on diabetes was delivered in isiXhosa and English. It used posters, games and health models to clarify its content. Changes to the quiz were implemented based on feedback obtained during the pilot study.

(ANOVA) procedures were performed to test the effects of age, gender and type of school (independent or government-funded) on quiz percentage scores before and after the intervention. Mean and standard error (SE) were calculated for pre- and post-intervention scores. All tests were performed using the statistical programming language R, with significance set at the 5% level. Separate analyses were performed on the junior and senior learners’ quiz results.

Ethical approval

The project was approved by the Rhodes University Pharmacy Ethics Committee (ref. no. PHARM 2016-6).

Data collection An interdisciplinary collaboration with the Department of Computer Science at Rhodes University, Grahamstown, resulted in the design of the computerbased quiz software using Microsoft PowerPoint (Microsoft, USA), and known as the BKnow program, to collect pre- and post-intervention data, while participants attempted to answer the computer-based quiz. School learners needed to use only three buttons on the computer keyboard while answering the quiz. Pharmacy students manning the exhibit instructed participants on how to operate the computer, as most of the schoolchildren who attended the NSF were from rural and township schools, and had little or no prior experience of using a computer.[22] Senior and junior students had separate quizzes. The pre-intervention questionnaire was followed by the intervention slide show on the computer. Immediately thereafter, the post-intervention questionnaire was made available.

Results

Intervention In addition to the interactive computer-based quiz, participants received an interactive presentation on diabetes, which included a model to demonstrate the benefits of a healthy diet and the consequences of an unhealthy one; a poster; an anatomical model of the alimentary system; a word search game; and a practical demonstration of the measuring tools for body mass index (BMI) and blood pressure. The anatomy board of the alimentary tract was used to show the organs affected by diabetes, and the interactive model on making healthy dietary lifestyle choices showed which choices predispose patients to diabetes. The poster was used to visualise and summarise information, and was presented to enhance the learning experience. Bilingual take-home leaflets (available in isiXhosa and English) were given to participants who attended the pharmacy health exhibition after the presentation. Thus they could take home basic information on diabetes to share with their families or community members. Schoolchildren received a word-search game, allowing interactive learning. The game reinforced key concepts associated with diabetes. The interactive presentation created a learning atmosphere for participants, which included schoolchildren, their parents and their teachers. The option to measure blood pressure and BMI was only available after receiving informed consent from volunteering participants.

Pre-intervention results Results from the pre-intervention questions, presented in Table 1, showed that learners had fair prior knowledge of diabetes, its effects, and how the disease can be prevented (overall mean score 52.8%). Questions 4 and 5 had the lowest correct percentage scores: ‘Why is insulin produced by the body?’ and ‘A person can prevent getting diabetes by eating what?' – for which 40.7% and 35.4% of the participants, respectively, provided correct answers. Conversely, Questions 2 and 7 had the highest correct scores: ‘Can uncontrolled diabetes cause death?’ and ‘If diabetes is uncontrolled, it leads to what?’ – for which 71.7% and 62.0% of the participants, respectively, answered correctly (Table 1).

Data analysis To assess whether the intervention made a difference in the understanding of diabetes, its causes and treatment, dependent t-tests on percentage scores for the junior and senior quizzes and McNemar χ2 tests on the percentage of correct answers obtained for each question before and after the intervention were conducted. Individual t-tests and analysis of variance

Junior learners

Demographics of the participants (age, grade, school and province of residence) were captured by the first 5 questions of the quiz, in which 113 learners took part. Data obtained show that 51 participants (45.1%) were ≤7 years of age, 23 (20.4%) were between 8 and 10 years, 27 (23.9%) between 11 and 13 years, and 12 (10.6%) were ≥14 years. Of the total, 65 (57.5%) were female and 48 (42.5%) male. Regional distribution showed that 102 (90.3%) were from the Eastern Cape, and the remainder were based in the other SA provinces. Demographics further showed that 88 (77.9%) participants attended government schools, while the remaining 25 (22.1%) attended private or independent schools. The numbers of learners who made use of or did not use computers at school were almost equal: 56 (49.6%) and 57 (50.4%), respectively.

Comparison of pre- and post-intervention results Of the 113 learners who answered the pre-intervention questions, 72 (64%) advanced to the post-intervention questions. To analyse the change in learners’ knowledge after the intervention, one-sided McNemar dependent χ2 tests were used. These results are presented in Table 1. The intervention resulted in a significant increase (p<0.05) in correct responses to Question 3, relating to what life would be like for children with diabetes (p=0.012). No significant improvement was observed in the number of correct answers given to any of the other questions. However, an improvement in the participants’ overall percentage score at the 5% significance level was noted (p=0.020). Results showed no significant gender differences for either the pre- or post-intervention mean (SE) percentage scores (pre-intervention, male: 54.0 (3.8)%, female: 53.6 (3.4)%; p=0.930; post-intervention, male: 61.1 (3.9)%, female: 62.5 (4.4)%; p=0.809). No significant difference in mean percentage score between participants from government and independent schools was

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Research noted before the intervention (pre-intervention, government: 55.2 (2.8)%, independent: 48.0 (5.7)%; p=0.257). However, after the intervention there was a significant difference at the 1% level (post-intervention, government: 65.5 (3.1)%, independent: 45.9 (6.2)%; p=0.006). No significant difference (p>0.05) was observed between the age groups for the pre-intervention mean percentage scores. However, a significant difference at the 5% level was noted for post-intervention scores (p<0.05) (Table 2). Significant differences were also noted between pre- and post-intervention scores for the following groups: (at the 0.1% significance level) for learners from government schools (p<0.001); (at the 0.1% significance level) for participants in the 11 - 13 age category (p=0.009); and (at the 5% significance

level) for male participants (p=0.018) and participants in the ≤7-year age category (p=0.027).

Senior learners

As in the junior school quiz, the demographics of the 255 participants in the senior quiz were captured by Questions 1 - 5. Data show that 62 participants (24.3%) were ≤12 years old, 84 (32.95%) were 13 - 15 years, 84 (32.95%) were between 16 and 19 years, and 25 (9.8%) were ≥20 years. Of the total, 141 (55.3%) were female and 114 (44.7%) were male. Regional distribution indicated that 235 (92.2%) attended or had attended a school in the Eastern Cape, while the remaining 20 (7.8%) were schooled elsewhere in SA.

Table 1. Junior school quiz results

Question 1. Diabetes is when your body has? 2. Can uncontrolled diabetes cause death? 3. Which of these statements is correct? 4. Why is insulin produced by the body? 5. A person can prevent getting diabetes by eating what? 6. Which of the following statements is incorrect? 7. If diabetes is uncontrolled, it leads to: Overall mean (%)

Correct answers (N=113), n (%) 66 (58.4) 81 (71.7) 60 (53.1) 46 (40.7) 40 (35.4) 55 (48.7) 70 (62.0) -

Correct responses for pre-intervention scores (N=72), mean (%) 40 (55.6) 51 (70.8) 41 (57.0) 27 (37.5) 29 (40.3) 39 (54.2) 44 (61.1) 53.8 (5.0)

Correct responses for post-intervention scores (N=72), mean (%) 43 (59.7) 51 (70.8) 54 (75.0) 30 (41.7) 33 (45.8) 47 (65.3) 53 (73.6) 61.7 (5.8)

p-value (one-sided) 0.677 1 0.012* 0.719 0.387 0.186 0.066 0.020*

*p<0.05.

Table 2. Pre- and post-intervention scores for different age groups (junior quiz) Age group, years ≤7 8 - 10 11 - 13 ≥14

Pre-intervention score, mean (%) 51.1 (6.1) 63.4 (7.1) 51.1 (4.8) 50.0 (9.8)

Post-intervention score, mean (%) 59.0 (7.1) 66.1 (8.3) 67.0 (5.6) 47.6 (11.4)

Analysis of variance, pre-intervention: F=1.439; df =3, 68; p=0.239; post-intervention: F=1.255; df =3, 68; p=0.297.

Demographics also showed that 232 (91.0%) and 23 (9.0%) participants attended government and independent schools, respectively. Some learners (n=137; 53.7%) responded that they had used computers at school before, while 118 (46.3%) had not. Pre-intervention results Results from the pre-intervention questions are shown in Table 3. Based on the results of the pre-intervention study, learners had fair prior knowledge of diabetes, its effects, and how it could be prevented (overall score 59.1%). Questions 9, 4 and 7 had the lowest correct scores. These were:

Table 3. Senior school quiz results

Question 1. What is diabetes? 2. How does someone get diabetes? 3. How does someone get to know if they have diabetes? 4. What is insulin? 5. Uncontrolled diabetes is a disease that may cause damage to what? 6. The onset of diabetes can be delayed or prevented by? 7. Which of the following is least likely to cause diabetes? 8. Why do we need to avoid obesity? 9. True or false: Uncontrolled diabetes can cause high blood pressure 10. Which of the following statements is incorrect? 11. Which of the following statements is correct? Overall mean (%) *p<0.05; **p<0.01; ***p<0.001.

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Correct answers (N=255), n (%) 189 (74.1) 200 (78.4) 183 (71.7) 88 (34.5) 134 (52.6) 172 (67.5) 117 (45.9) 135 (52.9) 86 (33.7) 179 (70.2) 174 (68.2) -

Correct responses for pre-intervention scores (N=139), mean (%) 114 (82.0) 113 (81.3) 101 (72.7) 48 (34.5) 78 (56.1) 99 (71.2) 66 (47.5) 83 (59.7) 44 (31.7) 98 (70.5) 99 (71.2) 61.7 (3.5)

Correct responses for post-intervention scores (N=139), mean (%) 113 (81.3) 115 (82.7) 113 (81.3) 58 (41.7) 93 (66.9) 108 (77.7) 87 (62.6) 90 (64.8) 75 (54.0) 104 (74.8) 113 (81.3) 69.9 (3.8)

p-value (one-sided) 1 0.860 0.074 0.175 0.041* 0.151 0.001** 0.391 <0.001*** 0.440 0.014* <0.001***

Research ‘True or false: Uncontrolled diabetes causes high blood pressure’, ‘What is insulin?’ and ‘Which of the following is least likely to cause diabetes?’. Results showed that only 33.7%, 34.5% and 45.9% of the participants answered the respective questions correctly. Questions 2 and 1, ‘How does someone get diabetes?’ and ‘What is diabetes?’, had the highest correct scores with 78.4% and 74.1% correct answers, respectively (Table 3). Comparison of pre- and post-intervention results Of the 255 senior school participants who answered the pre-intervention questions, 139 (55%) continued to the post-intervention ones. McNemar’s dependent one-sided χ2 test was used to analyse each question; the results are shown in Table 3. The intervention resulted in a significant increase in correct responses to four of the questions. Question 9 showed improvement at the 0.1% significance level (p<0.001), while Question 7 showed improvement at the 1% significance level (p=0.001). Furthermore, Questions 5 and 11 showed improvement at the 5% significance level (p=0.041 and 0.014, respectively). Improvement in the overall knowledge of participants after the intervention was significant at the 0.1% significance level (p<0.001). Results indicated no significant gender differences for either the preor post-intervention mean percentage scores (pre-intervention, male: 60.7 (2.5)%, female: 62.7 (2.5)%; p=0.582; post-intervention, male: 68.3 (2.7)%, female: 71.6 (2.8)%; p=0.389). No significant differences in mean percentage scores were found between participants from government and independent schools (pre-intervention, government: 62.5 (1.8)%, independent: 53.1 (5.70)%; p=0.121; post-intervention, government: 71.3 (2.0)%, independent: 56.6 (6.2)%; p=0.123). There were no significant agerelated differences in either the pre- or post-intervention mean percentage scores. The mean (SE)% scores of the participants in the age groups are shown in Table 4. Overall, significant differences were noted between pre- and postintervention mean percentage scores for the following groups: for participants in the 16 - 19-year age group, male participants, and learners from government schools (at the 0.1% significance level) (p<0.001 for each); and for female participants (at the 1% significance level) (p=0.002) and participants in the 13 - 15-year age group (at the 1% significance level) (p=0.002). It is interesting to note that no change took place in the mean percentage scores of the ≥20-year age group.

Discussion

The computer-based quiz was used for health education and as a mechanism for raising awareness and encouraging healthier lifestyle decisions, particularly among the young attendees at the NSF. This project targeted schoolchildren, as the health education they received could assist them in Table 4. Pre- and post-intervention scores for different age groups (senior quiz) Age groups, years ≤12 13 - 15 16 - 19 ≥20

Pre-intervention score, mean (%) 61.4 (4.3) 61.7 (5.3) 62.5 (5.1) 58.3 (7.4)

Post-intervention score, mean (%) 68.9 (4.6) 70.4 (5.7) 72.4 (5.6) 58.3 (8.0)

Analysis of variance, pre-intervention: F=0.129; df =3, 135; p=0.943; post-intervention: F=1.287; df =3, 135; p=0.282.

understanding aspects related to the prevention of diabetes. This approach is important, as it keeps a healthy population healthy. Evidence shows that more children are becoming obese and are thus increasingly prone to developing NCDs.[5] Therefore, the results are encouraging, as the majority (45.1%) of the junior school quiz participants were ≤7 years old. Child health education is important to address health literacy, especially in rural communities, where access to information is limited. Interestingly, demographic results obtained indicate that 90% of the junior and 92% of the senior school participants were from the Eastern Cape, the second poorest province in SA.[23] Diabetes is one of the major diseases contributing to the rise of NCDs, and the resulting mortality in the productive age group has a negative economic impact on individuals, families and governments in LMICs.[10,24] This further decreases the gross domestic product (GDP) of LMICs, where >75% of NCD-related mortality occurs.[25] The quadruple burden of diseases in SA[8,26] means that the poorest provinces, such as the Eastern Cape,[23] will be inordinately affected as the global burden of disease rises. By working towards the global goal of reducing NCD mortality rates by 2% yearly, significant improvements to the GDP and health coverage can be achieved,[25] along with a cost-effective health education tool. Both junior and senior school participants had fair prior knowledge of diabetes, according to pre-intervention quiz results. Only 64% of the junior and 55% of the senior school quiz participants in the pre-intervention questions advanced to the post-intervention ones. As most participants attended rural government schools, where the English language acts as a barrier to effective learning, lack of understanding of the questions might have been a factor that led to the participants not continuing to the postintervention questions. Moreover, as a significant improvement on the postintervention results was only observable for Question 3 for the junior school quiz, with no significant improvement with regard to other questions, it shows the need for more community engagement from pharmacy students as an intervention to promote health education and learning. Senior school participants’ overall knowledge on diabetes improved in the postintervention section. Demographics show that there were more female participants in both the senior and junior phase quizzes. A focus on female participants is important, as 42% of women in SA are obese.[27,28] Food companies, manufacturers and multinationals are profit centred, which has a detrimental effect on the population, because these stakeholders seek to influence WHO guidelines on sugar restrictions in favour of maximised profits.[29] World Health Day 2016 focused on diabetes mellitus; this health education was aligned to it.[30] Opportunities to design a poster, a bilingual information leaflet, a word-search game and a health model to explain healthy lifestyle choices, in addition to the interactive computer-based quiz, could have made this project unique for pharmacy students in developing a deeper understanding of the benefits of hands-on interactive health education. Use of multiple materials to focus on preventing and reducing NCDs offered an exciting and creative way of broadening the horizon of young participants.

Conclusion

The public health education exhibit on diabetes demonstrated the role of a cost-effective approach to reach out to the attendees and the broader community during an NSF. It accommodated learners from public and private schools, and illustrated ways in which health education aimed at children could lead to dissemination of health information for improved health literacy and disease prevention.

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Research Acknowledgements. The authors wish to thank the facilitators and students of the Khanya Maths and Science Club for their participation in pilot testing the quizzes. Mr N Borland is kindly acknowledged for his technical and logistics assistance. Drs R Tandlich and S Khamanga are acknowledged for their support. Author contributions. This health promotion project was carried out as a part of Mr M Mhlongo’s final-year BPharm research project. He manned the health promotion exhibit during the Scifest and was assisted adequately to write the first draft of the manuscript. Ms P Marara, a Master’s student working with Prof. S C Srinivas, was a mentor to Mr Mhlongo during the Scifest project and also assisted with manning the exhibit when Mr Mhlongo had to attend his practical or other academic commitments at the University. Ms Marara was also a mentor during the manuscript-writing phase. Dr K Bradshaw provided technical support related to the capture of the data during the Scifest and in analysing the data. Dr Bradshaw wrote the results section of the manuscrip. She edited the final version of the manuscript before submission and also when the reviewers’ feedback was received. Prof. Srinivas conceptualised and supervised the Scifest health promotion project. She also co-ordinated all the logistics required at various stages of the Scifest, such as pilot testing, setting up the exhibit and schedules of manning the exhibit, and edited the various drafts of the manuscript until completion. Funding. The Faculty of Pharmacy, Rhodes University, is gratefully acknowledged for the funding of this project. Funds from Rhodes University’s Inaugural Distinguished Vice-Chancellor’s Community Engagement Award made to Prof. Srinivas and Ms W Wrench are acknowledged. These funds supported the language-editing costs of this manuscript. Conflicts of interest. None. 1. World Health Organization. 2008 - 2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: WHO, 2008. 2. Raal FJ. The cardioprotective diet – carbohydrates versus fat. S Afr J Diabetes Vasc Dis 2015;12(1):4. 3. Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: The role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLOS Med 2012;9(6):e1001235. https://doi.org/10.1371/journal.pmed.1001235 4. Ahmed MSAM. Lifestyle measures for primary prevention of T2 diabetes mellitus (T2DM). Ind J Comm Health 2014;26(4):450. 5. Taggart J, Williams A, Dennis S, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract 2012;13:49. https://doi.org/10.1186/14712296-13-49 6. World Health Organization. Noncomunicable Diseases: Country Profiles 2014. Geneva: WHO, 2014. http:// www.who.int/nmh/countries/zaf_en.pdf?ua=1 (accessed 20 March 2016).

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7. International Diabetes Federation. IDF Africa members. 2015. http://www.idf.org/membership/afr/south-africa (accessed 20 March 2016). 8. Bradshaw D, Groenewald P, Laubscher R, et al. MRC Policy Brief: Initial Estimates from the South African National Burden of Disease Study, 2000. Cape Town: MRC, 2003. http://www.mrc.ac.za/policybriefs/ initialestimates.pdf (accessed 20 March 2016). 9. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet 2009;374(9693):934-947. https://doi.org/10.1016/S0140-6736(09)61087-4 10. Tasic L, Pesic V. Identification of risk factors for diabetes type 2 and components of pharmacists’ interventions in community pharmacy setting: A Serbian pilot study. Indian J Pharm Educ Res 2016;50(1):90-102. https://doi. org/10.5530/ijper.50.1.12 11. World Bank. World Bank open data: Population ages 15 - 64 (% of total). 2017. http://data.worldbank.org/ indicator/SP.POP.1564.TO.ZS (accessed 18 March 2016). 12. United Nations Development Program. Sustainable development goals. 2016. http://www.undp.org/content/ undp/en/home/sdgoverview/post-2015-development-agenda.html (accessed 2 May 2016). 13. Blom L, Krass I. Introduction: The role of pharmacy in patient education and counselling. Patient Educ Couns 2011;83(3):285-287. https://doi.org/10.1016/j.pec.2011.05.021 14. Irlam J, Pienaar L, Reid S. On being agents of change: A qualitative study of elective experiences of medical students at the Faculty of Sciences, University of Cape Town, South Africa. Afr J Health Professions Educ 2016;8(1):41-44. https://doi.org/10.7196%2FAJHPE.2016.v8i1.540 15. Mitchell B, Armour C, Lee M, et al. Diabetes medication assistance service: The pharmacist’s role in supporting patient self-management of type 2 diabetes (T2DM) in Australia. Patient Educ Couns 2011;83(3):288-294. https://doi.org/10.1016/j.pec.2011.04.027 16. Healthcare Information for All. About HIFA. 2015. http://www.hifa2015.org/about/hifa2015-in-context/ (accessed 21 March 2016). 17. Sawesi S, Rashrash M, Phalakornkule K, Carpenter JS, Jones JF. The impact of information technology on patient engagement and health behavior change: A systematic review of the literature. JMIR Med Inform 2016;4(1):e1. https://doi.org/10.2196/medinform.4514 18. Bandy J. What is service learning or community engagement. 2016. https://cft.vanderbilt.edu/guides-sub-pages/ teaching-through-community-engagement/ (accessed 20 March 2016). 19. Kruger SB, Nel MM, van Zyl GJ. Implementing and managing community-based education and service learning in undergraduate health sciences programmes: Students’ perspectives. Afr J Health Professions Educ 2015;7(2):161-164. https://doi.org/10.7196%2FAJHPE.333 20. Hamner J, Wilder B, Byrd L. Lessons learned: Integrating a service learning community-based partnership into the curriculum. Nurs Outlook 2007;55(2):106-110. https://doi.org/10.1016/j.outlook.2007.01.008 21. Mouton J, Wildschut L. Service learning in South Africa: Lessons learnt through systematic evaluation. Acta Acad Suppl 2005(3):116-150. 22. Srinivas SC, Wrench WM, Bradshaw K, Dukhi N. Diabetes mellitus: Preliminary health-promotion activity based on service-learning principles at a South African national science festival. J Endocrinol Metab Diabetes S Afr 2011;16(2):101-106. 23. Lehohla P. Poverty Profile of South Africa: Application of the Poverty Lines in the LCS 2008/2009. Pretoria: Statistics South Africa, 2012. 24. Horton R. Chronic diseases: The cause for urgent global action. Lancet 2007;370(9603):1881-1882. https://doi. org/10.1016/S0140-6736(07)61701-2 25. Abegunde D, Mathers CD, Adam T, Ortegon M, Strong K. The burden and cost of chronic diseases in low-income and middle-income countries. Lancet 2007;370(9603):1929-1938. https://doi.org/10.1016/S0140-6736(07)61696-1 26. Perez AM, Ayo-Yusuf O A, Hofman K, et al. Establishing a health promotion and development foundation in South Africa. S Afr Med J 2013;103(3):147-149. https://doi.org/10.7196%2FSAMJ.6281 27. South African Medical Research Council. South African women show high levels of obesity and overweight. 2014. http://www.mrc.ac.za/Media/2014/14press2014.htm (accessed 29 May 2014). 28. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980 - 2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384(9945):766-781. https://doi.org/10.1016/S0140-6736(14)60460-8 29. Stuckler D, Reeves A, Loopstra R, McKee M. Textual analysis of sugar industry influence on the WHO's sugars intake guideline. Bull World Health Organ 2016;94(8):566-573. https://doi.org/10.2471/BLT.15.165852 30. World Health Organization. World Health Day 2016: Beat diabetes. 2016. http://www.who.int/campaigns/worldhealth-day/2016/en/ (accessed 9 March 2018).

Accepted 14 September 2017.

Research

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

Engagement of dietetic students and students with hearing loss: Experiences and perceptions of both groups Y Smit, BSc Diet, M Nutrition; M Marais, BSc Diet, M Nutrition; L Philips, BSc Diet, M Nutrition; H Donald, BSc Diet; E Joubert, BSc Diet Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: Y Smit (yolandes@sun.ac.za)

Background. Final-year dietetic students from Stellenbosch University (SU) present selected training sessions during their Rural Clinical School (RCS) rotation to professional cookery students of the National Institute for the Deaf (NID). Objective. To describe experiences and perceptions of dietetic students and NID students before and after training sessions. Methods. A descriptive, phenomenological approach was followed. SU students (N=23) reflected on experiences before and after providing training to NID students. Two focus group discussions were conducted with NID students (N=19) after training to explore their experiences related to the training. An experienced interpreter facilitated discussion topics using South African Sign Language (SASL). Voice recordings were transcribed verbatim and thematic content analysis was performed manually. Results. NID students described feelings of uncertainty and fear of the unknown prior to the training. These feelings turned to excitement and curiosity as the presentations continued. They were positive about the learning experience and described it as wonderful and interesting. SU students described it as challenging, but valuable in gaining insight into living with deafness. The experience positively influenced their professional and personal development. Students were appreciative of and grateful for the opportunity to engage with and learn from each other. Suggestions were made to improve future training sessions based on identified barriers, such as overcoming communication challenges and clarifying reciprocal misperceptions. Perceptions changed when similarities between student groups were realised. Conclusion. The overwhelmingly positive experience of both groups is a strong motivation to continue with this initiative. SU students recognised the importance of health promotion to persons with impairments. Afr J Health Professions Educ 2018;10(1):31-37. DOI:10.7196/AJHPE.2018.v10i1.901

hen referring to the audiological condition of deafened individuals, W ‘deaf ’ is used. An uppercase D is used when writing about Deaf Culture, a group with which many prelingually deaf individuals affiliate themselves. Culturally Deaf individuals have their own language, specific customs and ways of behaving.[1] The deaf and persons with hearing loss (D/HL) are a minority group worldwide that faces challenges to achieve optimal health owing to various factors,[1-4] such as inequities in accessing healthcare, low reading levels, writing levels that often do not exceed those of 6th-grade English pupils,[3,5] not understanding health-related terminology, with a resultant inability to interpret written prescriptions,[5] missed appointments and misunderstood diagnoses.[1] D/HL find the attitude of healthcare professionals (HCPs) patronising, creating a barrier between them and HCPs in general. Due to poor communication, there is very little transfer of information, leading to inaccurate interpretations by D/HL, which may negatively affect health outcomes.[1,2,5] There is a need to educate HCPs about the unique problems faced by D/HL,[2,4] as even well-educated deaf individuals may have difficulty understanding written English. Mastering of basic sign language by HCPs could help to build trust during consultations, as the use of interpreters could lead to fear of being judged by the interpreters[1] and has the potential of breaching confidentiality[5] and privacy. Enhancing these communication skills among HCPs will comply with the development of professional competencies that extend beyond disciplinary expertise or

technical knowledge, such as those of communicator, collaborator, scholar, health advocate, manager and leader.[6] The Rural Clinical School (RCS) of the Faculty of Medicine and Health Sciences (FMHS) of Stellenbosch University (SU) is based in Worcester, Western Cape Province, South Africa (SA). The RCS provides students from FMHS with exposure to rural community health, allowing for reallife experiences during their placement at the RCS and rendering services in a rural community setting.[7] It further promotes community-orientated education and training through engagement of students via a multitude of learning activities in under-served areas.[7] Final-year dietetic students complete a 6-week rotation at the RCS as part of their internship, thereby providing services at various facilities in the Worcester district. RCS facilitators affiliated to the Division of Human Nutrition, SU, have fostered relationships with several community partners (Box 1). One of these partners is the National Institute for the Deaf (NID), a private training institution registered with the Department of Higher Education and Training (DHET) that caters for specific training needs of deaf students. The NID offers hospitality courses, one of which is Professional Cookery (PC). The main aim of these courses is to increase employability of these special needs students.[8] The NID employs a multidisciplinary approach to their teaching to meet the diverse needs of their students.[8] ‘Deaf students are not simply hearing students who cannot hear’,[9] is a message continually emphasised by numerous researchers in the field of D/HL education.[1,2,5,9-11] The literature reports that the cognitive functioning of D/HL differs

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Research Box 1. Context The RCS rotation allows students the opportunity to experience how different dietetic subjects link with one another and where the translation of theoretical knowledge into practical skills is practised through appropriate responses to the health needs of community members.[13] An assignment introduced in 2014 involved dietetic students who had to give presentations to NID students on nutrition-related topics not covered in the NID professional cookery curriculum. This assignment contributed to the enhancement of professional competencies of SU students in more than one way. After consultation with the NID co-ordinator, topics for four training sessions were identified: (i) healthy eating; (ii) healthy cooking methods; (iii) meal planning; and (iv) menu planning. Training material developed by the SU students was evaluated prior to the training sessions by two lecturers from SU and one lecturer from the NID for conciseness, accuracy and suitability for the target group. Training sessions were limited to 3 hours and comprised two components: a theoretical component presented in a classroom and a practical session in a wellequipped kitchen. The ratio of the SU:NID students was 4:10. In preparation for their duties during the RCS rotation, dietetic students attended an introductory session of one of the NID lecturers regarding the skills necessary to communicate with persons with hearing loss.

from that of hearing learners and may possibly affect learning, language comprehension and literacy.[1,2,5,11,12] Contact with NID students provides an opportunity to raise awareness among SU students of the unique needs of the D/HL.[2,11] Currently, the literature on the experience of HCPs providing services to D/HL relates to medical, nursing, occupational therapy and speech therapy professionals or students.[14] This study is the first to explore the experiences of dietetic students in providing health-promotion sessions to deaf students, a vulnerable group,[4] who have the right to health and to be informed.[4] They are more likely to be forgotten in healthcare programmes owing to language differences, health knowledge limitations and cross-cultural differences.[4,11.15] The literature reports that HCPs expressed feelings of fear, anxiety and discomfort when dealing with D/HL patients,[11,14] as well as lack of knowledge and experience in counselling them.[14] For HCPs to communicate effectively[11] and build a relationship of trust[4,5,11] with D/HL, they need the knowledge and skills to adapt to the special needs and preferred way of communication of this group.[1,5,11] Satchidanand et al.[14] report that previous training and experience in treating persons with physical disabilities furnish HCPs with more favourable attitudes. As SU dietetic students have the unique opportunity to interact with deaf students, this article reports the experiences and perceptions of both groups of students after four training sessions, including perceived barriers to successful training.

Methods

Study participants

A qualitative, descriptive phenomenological approach (Fig. 1) was followed to describe the lived experiences of the study participants.[16] All NID students (N=19) registered for the professional cookery module and finalyear dietetic students (N=23) provided consent and were included in the study. All NID students included in this study were fluent in SA Sign Language (SASL).

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Descriptive Phenomenological approach Professional cookery students (NID: n=19) Focus group discussions (using SASL)

Dietetic students (SU: n=23) Reflections (pre/post)

Inductive content analysis

Fig. 1. Study design and population (N=42). (SASL = South African Sign Language; NID = National Institute for the Deaf; SU = Stellenbosch University.)

Data collection

Data were collected in 2015 in Worcester using structured reflections of the SU students and focus group (FG) discussions with the NID students. SU students (N=23) completed two separate structured written reflections based on their experiences pre- and post-training. Students have been guided in the skill of reflecting since their 2nd year of study. The threestage model of reflection guided students to capture the ‘what’ (describe experience and emotions), ‘so what’ (describe importance) and ‘what now’ (describe influence on professional development).[17] According to the literature, FG discussions are regarded as a more suitable research method to elicit responses from the PC students,[15,18] as SASL is the preferred means of communication for the deaf.[11,15,19] In the Deaf culture, people share information and openly discuss even sensitive topics in groups.[4,19] Furthermore, it is possible that reflections and questionnaires would not be a reliable method of obtaining data in this group of students, as vocabulary and sentence construction are different when using SASL.[15] A FG discussion guide compiled by the researchers consisted of questions and probes to investigate NID students’ perceptions of being trained by dietetic students, learning experiences, as well as barriers to successful training and suggestions for improvement. The FG discussion guide was sent to two NID lecturers before the FG discussions to evaluate the validity of its content. The face validity was also assessed by NID lecturers to ensure that the questions and probes were phrased correctly to optimise the use of SASL by the interpreters. Two FG discussions (n=10, n=9) with the NID students, guided by the FG discussion guide, were conducted by an SU lecturer after their fourth training session. The RCS facilitator(s) assisted with obtaining informed consent, managed the voice recordings and acted as an observer. The FG discussions were held at the NID College, and were conducted in a classroom that was familiar to the NID students and the interpreter. NID students were seated facing the interpreter to ensure that the facial expressions and hand signs of the interpreter were clearly visible.[5] A trusting relationship between an interpreter and the deaf is deemed important to optimise the dynamics of the discussions.[20] An interpreter with 32 years of experience facilitated communication using SASL. Fortunately, after 10 years of employment at the NID, the interpreter was familiar with the different dialects used by NID students. The interpreter signed the questions asked by the SU lecturer and verbalised the responses given by the NID students for voice-recording purposes. Probes were used to encourage further input from NID students, and the SU lecturer had an opportunity to ask for clarification or restating

Research of the issue if misunderstanding arose. The duration of the FG discussions was 45 minutes, by which time data saturation was reached, as discussions started to deviate from the topic.

Data analysis

Voice recordings of the FG discussions were transcribed verbatim. Transcriptions were checked to ensure that the text was a true reflection of the recorded interviews. A systematic approach was used to do content analysis. An inductive process was followed, as common themes emerging from the text were used to compile a code list and themes were grouped into categories.[21] To enhance validity and limit possible inconsistencies, the text was independently re-read by two researchers. A third researcher was consulted if there was uncertainty, which allowed consensus to be reached before the findings were reported. The same content analysis process was performed for the written reflections and the voice recordings. The reflections and FG discussions were analysed separately using the same framework, but reported simultaneously. The findings were reviewed by the NID co-ordinator to verify accuracy and ascertain that the information was disseminated appropriately.

Ethical approval and legal aspects

Approval to perform the study was granted by the Health Research Ethics Committee of the FMHS, SU (ref. no. S13/10/210), and permission to conduct research on students was subsequently obtained from the Division of Institutional Planning, SU, as well as the NID College co-ordinator. All participants in the study provided written informed consent in their language of choice (Afrikaans or English). Consent forms for NID students were amended using simplified terminology. The forms included a separate section for voice recording of the FG discussions. The consent forms were explained by the NID co-ordinator and all students were provided with an opportunity to clarify queries before signing the forms. Voice recordings were password-protected and destroyed after completion of the research, while interview data and reflections were stored separately from the consent forms. Anonymity and confidentiality were ensured, as it was not expected of participants to identify themselves at any point. The information will be disseminated by sending copies of the final article to all participants to assure them that their participation made a contribution to the education of HCPs.[5]

Results

Sociodemographic information

The study participants were mostly female and <24 years of age (Table 1).

Students’ responses before training

The main themes identified before training were emotions, expectations and insight. Table 1. Demographic information of students Male, n (%) Female, n (%) Age (yrs), mean (SD)

SU students (n=23) 0 (0) 23 (100) 22 (0.99)

SU = Stellenbosch University; NID = National Institute for the Deaf.

NID students (n=19) 8 (42.1) 11 (57.9) 24.15 (3.59)

Emotions SU students felt positive and optimistic about the assignment that they had received. Although many conveyed mixed feelings at the onset, these were mainly due to excitement at the challenge ahead of them, combined with the uncertainty of exploring relatively unknown territory. This uncertainty stemmed largely from ‘having no previous experience communicating personally with hearing-impaired persons’: ‘Receiving the task of presenting to the NID students, strengthening their knowledge on healthy eating and healthy lifestyle choices was very exciting, as this is a challenge I have never been confronted with, and an important skill for me to develop to grow best as a holistic professional.’ (SU student) NID students shared comparable sentiments, as they were positive about the learning experience, described varying emotions when they learnt of the training sessions and wondered ‘who these people were’. NID students were initially apprehensive, ‘scared and shocked’ when they were informed about the purpose of the presentations by the SU students. Expectations SU students realised the possibility of not only teaching the NID students, but at the same time benefiting from their time together as ‘… there is no better way to learn how to work with people that are different to you than to spend time with them’. They regarded this as a unique opportunity that would afford them the chance to interact with deaf students, instil confidence, encourage ‘out of the box’ thinking and experience overall growth as HCPs: ‘Being exposed to as many different target audiences as possible will expand our skill levels and adaptability as professionals, and working with hearingimpaired students will allow us to develop a sense of understanding and respect which would not be achieved otherwise.’ (SU student) ‘I think there is so much they can share with us that we would never have known before had we not been put in this situation.’ (SU student) NID students were also positively curious and expressed hope for developing reciprocal relationships. Students admitted to ‘not knowing what to expect’ and not knowing what the sessions would entail. Insight SU students admitted to ‘not knowing what to expect’ before the training. They had a preconceived idea that they would need to move out of their ‘comfort zones’ to adapt to the needs of deaf students, which led some to experience feelings of doubt, pessimism and discomfort. SU students expressed anxiety and perceived intimidation on presenting food preparation techniques to culinary students owing to an apparent threat of prior above-average knowledge of NID students in this field.

Students’ responses after training

The main themes identified after completion of the training were insight, communication, impact of training and barriers to optimal learning. Insight The SU student group recounted feelings of admiration and respect for their fellow NID students. Although the NID students were initially perceived as

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Research being shy, the increasing time spent together allowed students to relax. As time wore on, the NID students became more animated and were actively engaging in the training sessions. SU students appreciated the friendliness and positive attitude of the NID students. Several students noted the absence of self-pity of the NID students, and were subsequently motivated and inspired by their empowering attitudes, passionate communication and teamwork. Their prowess and knowledge in the kitchen were admired by the SU students, as was their thirst for knowledge and active participation during the sessions. SU students came to realise that, despite previous misconceptions about students with hearing loss, their affective abilities were no different from those of other students, such as thinking, interaction or possessing an enquiring mind: ‘A perception that definitely changed during the activity was the realisation that hearing-impaired students are just like any other students in their interaction with each other and within the learning environment.’ (SU student) The overall sentiment of SU students on completion of the training sessions was one of appreciation and gratitude. They were overwhelmingly positive about the experience and described it as being ‘rewarding’, ‘enriching’, ‘inspiring’, ‘indispensable, ‘an eye-opener’ and ‘better than I could ever have anticipated’. Similarly, NID students felt it was ‘wonderful’ and ‘interesting’: ‘I was surprised at one point when a student [NID] burst into laughter for some or other reason. The outburst of delight among a room full of quiet reminded me that these students with such a disability as deafness, still experience laughter and pain.’ (SU student) Value of communication Despite some frustrations, the end-goal was ultimately achieved as SU students began to realise the importance of communication in their everyday lives, both personally and professionally. With time, SU students adapted their approach and began to modify rate and tone of speech, sentence structure and complexity of messages to facilitate easier translation. SU students also realised the need to talk directly to the deaf students (as they tended to address the interpreter) and not use confusing hand gestures, which resulted in greater confidence in speaking to this particular target population: ‘I found it extremely rewarding and amazing to see the [NID] students’ facial expressions and realise that they understood what I was saying through the interpreter.’ (SU student) Working with an interpreter was a challenging but enlightening experience for the SU students. They were positive about the presence of the interpreter, but at times felt uncomfortable with longer periods of silence or talking slowly. They realised later that the deaf students did not perceive this as uncomfortable because it is their ‘normal’. Even in situations where the interpreter was not available on a one-onone basis, SU students were able to improvise and make use of simple visual and non-verbal cues to communicate on a basic level with the NID students. ‘This made me realise how we actually don’t realise how easy it is for us to communicate with one another.’ This fostered a feeling of accomplishment among the SU students. The majority of SU students were grateful for this opportunity to rethink the value of conveying simple, yet effective, messages to their audiences.

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Although the SU students might have felt initial trepidation with regard to interacting with NID students, the latter group was grateful for the attempts made to communicate, be it via simple hand gestures or writing messages to one another: ‘It stretched the abilities I thought I had and showed me that with a bit of confidence and a good attitude, I can talk to anyone – even if they can’t hear me.’ (SU student) Impact of learning activity SU students were appreciative of skills gained and commented on improved confidence levels, being less apprehensive in new environments, being able to ‘think on their feet’, as well as gaining invaluable practical experience in dealing with diverse target audiences. ‘I understand how this task can help us to grow as dietitians – it broadens our scope, our knowledge.’ Their role as health professionals became clearer in terms of seeing how working with individuals with any form of disability would affect them in their future professions: ‘Everyone has the right to education, no matter their background or disability and we need to all respect everyone and be aware of what is going on around us.’ (SU student) SU students also expressed personal anecdotes of how the experience had strengthened their levels of gratitude at being blessed with the ability to hear, becoming more patient and respectful of those with disabilities and to be more open-minded when faced with new experiences: ‘I personally feel that engaging with people/patients with disabilities is often overlooked, despite the fact that there is a large population of South Africans who are living with disabilities, and require dietetic services/ health knowledge.’ (SU student) NID students realised the potential impact of pooling resources and learning from one another. ‘We can also teach them what we know. So we can teach each other.’ NID students expressed a deep desire for more intricate and in-depth learning opportunities. They wanted to know more about healthy eating and the role of the dietitian in the greater community. ‘They teach us the basics, but we want to learn something a little bit more difficult; what dietitians can do; things dietitians do.’ NID students were also thankful to have benefited from knowledge dissemination, and mentioned that ‘it was something new to learn’ and that they had ‘heard some information for the first time’. The students particularly enjoyed the practical sessions more than the theoretical presentations and described them as being ‘nice’. ‘They didn’t complain when we made mistakes, they just encouraged us to work on our future.’ On a personal level, the SU students motivated the NID students to ‘eat healthy’ and the NID students felt that ‘without the training, if people had asked about healthy food, we never would have known about it, so this [the training] was good’. Barriers SU students described occasional frustration at not being able to communicate optimally with the NID students. The desire to be able to interact with the deaf was often overshadowed by feelings of helplessness, as they needed to rely on the interpreter to facilitate an interactive conversation: ‘There were so many occasions where I just wanted to talk to them and get to know them but because I was unable to communicate in a way that they

Research would understand, this was impossible. It was such a frustrating feeling that I have never experienced before.’ (SU student) Despite planning the sessions in advance, SU students discovered that the actual training was a lengthier process than they had anticipated, given the need for interpretation, which often relied on greater concentration and adaptability on their part. They also expressed concerns that NID students would perceive them as being ‘condescending’, given the need to speak more slowly than they would usually do. On occasion, some SU students left immediately after the training was concluded owing to commitments elsewhere and several NID students considered this as being rude. The perceived apprehension of the SU students towards the NID group was seen as a barrier. A lack of confidence in communication skills and discomfort on the part of the SU students could have been erroneously interpreted by the NID students as a lack of interest in communicating with them, when it could rather be explained by a feeling of uncertainty or difficulty adapting to a new environment: ‘So are they scared of deaf people? Are they scared to talk to us? What is the problem … why are they never communicating with us?’ (NID student) The curiosity regarding the dietetic students distracted NID students from focusing on the discussion topics. NID students expressed a need to learn more about the SU students on a personal level by spending more time with them on an informal basis. To summarise, feelings of discomfort and uncertainty soon eased when the SU students were welcomed on the NID campus, where an atmosphere of calm, peace and hospitality prevailed. A few SU students admitted to feeling slightly uncomfortable at the difference in communication techniques and felt fortunate at being blessed with the gift of hearing. NID students expressed feelings of appreciation towards the SU students for trying to forge relationships with them, despite communication barriers. The experience was insightful and changed the reciprocal perceptions of both groups. It is important that SU students are equipped with the skills necessary to facilitate communication with persons with hearing loss. Maintaining collaboration with the NID College serves as an opportunity to facilitate the translation of knowledge to students with hearing loss.

Discussion

Positive feedback from dietetic students who completed the assignment during previous years led to the question of whether the NID students had the same experience and whether the assignment should be repeated. Recommendations could be made to improve training sessions for the benefit of persons with hearing loss. Deaf students are more heterogeneous than their hearing-abled peers and vary in their cognitive abilities and knowledge.[4,11,12,22] The unique study population facilitated an enriching experience embraced by both groups of students. Even so, it is crucial to bear in mind that the majority of participants were female, which could have influenced the finer nuances of the discussions and reflections as female HCPs have more favourable attitudes towards persons with physical disabilities.[14]

Experiences and insight

SU students admired the absence of self-pity on the part of the NID students, and were subsequently motivated by their empowering attitudes,

passionate communication and teamwork. It was inspiring that this group of students with hearing loss were very positive and appreciative of the efforts of SU students, not only in conveying new knowledge, but also in engaging with them. These findings contradict findings of Furnham et al.,[23] who reported that deaf students had the perception that hearing individuals have more negative attitudes to deafness than they actually have. It could possibly be explained by NID students being unaware that dietetic students form part of HCPs, and therefore did not project the mistrust or anger towards HCPs as reported elsewhere.[5,11,19] SU students learnt not to underestimate the abilities of students with hearing loss purely on the basis of their living with a disability. As a communicator, an HCP needs to have the ability to develop rapport, trust and ethical therapeutic relationships with clients from different backgrounds, having distinct skills and competencies.[6] This role of communicator links strongly to the required graduate attributes that have been widely embraced by the health science curricula of SU.[24] The invaluable role of communication, not only in day-to-day existence, but also in the essential role of fostering optimal healthcare, was realised by the students. NID students responded well to the effort of the SU students to communicate, which may be due to deaf students’ ability to make inferences and connections with world knowledge associated with incidental learning, enabling them to react appropriately.[11,25] The active engagement of D/HL students proves that even with linguistic difficulties it is both important and feasible for them to participate in research.[15] HCPs need to be educated with regard to the barriers experienced by individuals from the Deaf culture relating to access to healthcare.[1,3,4,11] Effective communication can be improved via frequent contact of students with the Deaf culture during their training.[14] The experience of interacting with the deaf contributed to the professional and personal development of final-year dietetic students and added to a deeper understanding of the different dimensions of their role as healthcare advocates.[6] SU students’ ability to recognise the importance of health promotion to individuals with disabilities and not limiting valuable health-promotion messages to only hearing-abled individuals exemplifies their role as scholar[6] to disseminate and translate nutrition knowledge to the broader community.[5,19] As D/HL students have different backgrounds and experiences than hearing-abled students, both their knowledge and learning strategies differ. Marschark[9] describes deaf learners as ‘visual-learners’, which explains why NID students clearly enjoyed the practical part of the training sessions the most.[3] The literature advises the use of visual aids[19] and a variety of media, including videos using sub-titles.[5] Deaf learners fluent in sign language have the ability to generate complex visual images.[9,12] It was therefore deemed appropriate to conduct FG discussions, facilitated by an interpreter fluent in SASL, to gain insight into the way the NID students experienced the training provided by hearing students.[18] Theoretically, it would have been ideal to obtain written reflections from the NID students, but this was not practical. Most D/HL display lower vocabulary levels compared with hearing peers owing to their limited access to full, fluent language.[3,10,26,27] Having smaller FGs might be considered in future, as 5 - 8 participants per group are advised for the deaf.[20] Fluency in a sign language is a predictor of reading level, as research shows that those most proficient in a sign language were better readers. Recent literature found that post-secondary students learned just as much from text as they did from sign language, despite the reading difficulties they experienced.[10] Therefore, printed information leaflets to

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Research support the messages conveyed during practical training sessions can be beneficial, provided the necessary modifications of materials are made to accommodate their needs,[20,28] such as using an easy handwriting/font type and basic vocabulary that does not exceed 6th grade reading level.[5] Deaf learners can learn as much as their hearing peers when taught by skilled teachers of the deaf.[9] A clear understanding of the content of previous modules and the level of knowledge are crucial when developing new training material.[9] Prior knowledge of the curriculum enables SU students to build on the existing knowledge of the NID students to open up a world of new information to them. Training sessions presented by the SU students successfully complemented the PC course. Future collaboration between the two parties should therefore be encouraged, as NID students requested more information.

Perceived barriers experienced during the training

The desire to be able to interact with the hearing-impaired group was often overshadowed by feelings of helplessness, as SU students needed to rely on the interpreter to facilitate an interactive conversation. Uncertainty surrounding the role and competencies of each group was explicitly expressed by both groups. SU students were afraid of being viewed as condescending, whereas the NID students perceived them to be rude owing to SU students’ seeming inability to reach out. Meador and Zazove[5] report that in the Deaf culture, it is considered rude to be excluded from any conversation, which easily happened when SU students had private discussions among themselves or had to leave suddenly at the end of a contact session. Helen Keller is quoted as saying that ‘being deaf isolates one from people’.[5] Spending more time together on an informal level[1] could help to diffuse the tension, as both groups tended to relax after a while and adopt a reciprocal attitude of tolerance and appreciation. Sarchet et al.[10] conclude that ‘differences between students with hearing loss and hearing students do not necessarily reflect unsurmountable challenges but they do need to be acknowledged by students, instructors, and institutions if all are to succeed in the educational endeavour’. Research shows undeniably that HCPs lack the knowledge and skills to communicate effectively with the D/HL, as very few acquire SASL skills[2] and would benefit from having more opportunities to serve individuals with physical disabilities.[4,14] The need expressed by the NID students for healthcare students to learn at least a few signs[3] corresponds with the current literature.[2,11] Healthcare students need to be sensitised and encouraged to make a concerted effort to be cognisant of the Deaf culture and values.[1,2] Healthcare information disseminated in an appropriate manner could help this minority group receive quality healthcare, participate and feel valued as persons[5,20] and decrease anxiety and fear of HCPs.[1]

Study limitations

The researchers were cognisant of the limitations of analysing the Englishlanguage translations of SASL conversations. The richness of emotions of NID students, as evident by sentiments such as being ‘shocked’ in anticipation of the training session, was probably limited by using SASL. The literature shows that students with hearing loss tend to overestimate their understanding and learning from reading and lectures.[10] The question arises as to how accurate the NID students’ expression of emotions was, despite the prompting by an experienced SASL interpreter. Greenbaum[18] suggests using two interpreters, as often one will be able to understand something the other could not.

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Recommendations

To build trust and understanding, facilitators are encouraged to arrange additional contact sessions in the form of visits to both campuses and social interaction prior to the academic sessions. Using smaller groups for discussion with deaf students could potentially provide greater insight regarding their perceptions and specific needs. Hearing students should ideally develop a clear understanding of the context of the proposed module content and the knowledge level of the persons with hearing loss to apply the correct context and enable the ‘training’ students to build on the existing knowledge of the hearingimpaired students. Communicating with individuals with hearing loss can also be strengthened to establish a trust relationship and encourage participation by acquiring basic sign-language skills, specific presentation proficiencies and communicating via a trained SASL interpreter. Practical sessions that allow for hands-on demonstrations and greater communication between groups should be prioritised, as well as the importance of relaying feedback during and after each training session. The provision of hand-outs tailored to the linguistic needs of individuals with hearing loss is essential. Deaf students should ideally also be provided with some background information regarding the dietetic students before the training sessions commence. This information could include snippets on the dietetic profession and curriculum to ease anxiety before the training. A desire for a deeper level of learning about healthy eating was also expressed, and could perhaps be incorporated into the PC curriculum in the near future.

Conclusion

Findings of this research provide some understanding of the way deaf students experienced training sessions provided by dietetic students. SU students were challenged to perform an assignment that required them to think and act innovatively, which appears to have been a valued experience in empowering them to effectively fulfil their role as HCPs. SU students were apprehensive prior to training commencement, but these emotions changed during the presentation of the training. SU students agreed that the assignment helped them to better understand the challenges that deaf persons face every day and subsequently gained respect for them. Preconceived ideas that NID students might not understand their training messages or that they were very different to the SU students were altered. The activity had a positive impact on both their personal and professional growth and development, as they gained increased confidence in working with individuals with disabilities. As evidenced by the mutually beneficial outcome of this project and the overwhelmingly positive experience from both student groups, it is suggested that the collaboration between the NID and Division of Human Nutrition, SU, be continued and strengthened in the future. NID students were appreciative of the efforts to reach out to them and were keen to acquire new knowledge, which they claim to also utilise in their private lives. Acknowledgements. We express our gratitude towards the NID co-ordinator and lecturers, NID students and SASL interpreter for inviting us into their deaf world. The contributions of the BSc Dietetics final-year students (2015) were invaluable.

Research Author contributions. YS, MM, EJ: study completion and design; YS, HD, EJ: data collection; YS, MM, LP: data analysis and interpretation; YS, MM, LP, HD: conceptualising and writing the manuscript. Funding. Financial support was provided by the SU Fund for Innovation and Research in Rural Health (FIRRH) and the SU Rural Medical Education Partnership Initiative (SURMEPI). Conflicts of interest. None. 1. Scheier DB. Barriers to health care for people with hearing loss: A review of the literature. J New York Nurses Ass 2009:4-10. https://doi.org/10.1097/PHM.0b013e3182555ea4 2. Sadler GR, Huang JT, Padden CA, et al. Bringing health care information to the deaf community. J Cancer Educ 2001;16:105-108. https://doi.org/10.80/08858190109528742 3. Barnett S. Deaf sign language users, health inequities and public health: Opportunity for social justice. http:// blogs.cdc.gov/pcd/2011/02/15/ (accessed 14 February 2017). 4. Munoz-Baell IM, Ruiz MT. Empowering the deaf. Let the deaf be deaf. J Epidemiol Comm 2000;54:40-44. https:// doi.org/10.1136/jech.54.1.40 5. Meador HE, Zazove P. Health care interactions with deaf culture. J Am Board Fam Prac 2005;18(3):218-222. https://doi.org/10.3122/jabfm.183218 6. Frank JR, ed. The CanMEDS 2005 Physician Competency Framework. Better Standards. Better Physicians. Better Care. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2005. 7. Stellenbosch University, Faculty of Medicine and Health Sciences. Faculty Home/About us. 2016. http://blogs. sun.ac.za/ukwanda/ukwanda-rural-clinical-school/why-a-rural-clinical-school/ (accessed 17 November 2016). 8. National Institute for the Deaf. http://www.nid.otg.za/college/about.html http://www.nid.org.za/ (accessed 17 November 2016). 9. Marschark M. How deaf children learn. https://global.oup.com/academic/product/how-deaf-childrenlearn-9780195389753 (accessed 17 November 2016). 10. Sarchet T, Marschark M, Borna G, Convertino C, Sapere P, Dirmyer R. Vocabulary knowledge of deaf and hearing postsecondary students. J Postsecond Educ Disabil 2014;27(2):161-178. 11. Barnett S. Communication with deaf and hard-of-hearing people: A guide for medical education. Acad Med 2002;77:694-700. 12. Marschark M, Knoors H. Educating deaf children: Language, cognition and learning. Deaf Educ Int 2012;14(3):136-160. https://doi.org/10.1179/1557069X12Y.0000000010 13. Ukwanda Rural Clinical School, Stellenbosch University. htttp://www.blogs.sun.ac.za/ukwanda/ukwanda-ruralclinical-school/ (accessed 17 November 2016).

14. Satchidanand N, Gunukula SK, Lam WY, et al. Attitudes of healthcare students and professionals toward patients with physical disability. A systematic review. Am J Phys Med Rehabil 2012;91(6):533-545. https://doi. org/10.1097/PHM.0b013e3182555ea4 15. Bisol CA, Sperb TM, Moreno-Black G. Focus groups with deaf and hearing youths in Brazil: Improving a questionnaire on sexual behaviour and HIV/AIDS. Qual Health Res 2008;18(4):565-578. https://doi. org/10.1177/1049732307307868 16. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. 3rd ed. Thousand Oaks, CA: Sage Publications, 2013:58. 17. Toole J, Toole P. Part V: Reflections as a Tool for Turning Service Learning into Learning Experiences. In: Kinsley C, Macpherson K, eds. Enriching the Curriculum Through Service Learning. Alexandris, VA: Association for Supervision and Curriculum Development, 1995. 18. Greenbaum T. Conducting focus groups with disabled. 2000. http://www.groupsplus.com/pages/disabled.htm (accessed 17 November 2016). 19. Steinberg AG, Barnett S, Meador HE, Wiggins EA, Zazove P. Health care accessibility. Experiences and perceptions of deaf people. J Gen Intern Med 2006;21:260-266. https://doi.org/10.1111/j.1525-1497.2006.00340.x 20. Fraser M, Fraser A. Are people with learning disabilities able to contribute to focus groups on health promotion? J Adv Nurs 2001;33(2):225-233. https://doi.org/10 1111/j.1365-2648.2001.01657x 21. Skinner D. Qualitative research methodology: An introduction. In: Joubert G, Ehrlich R, eds. Epidemiology: A Research Manual for South Africa. 2nd ed. Cape Town: Oxford University Press, 2008:318-326. 22. Hirsch ED. Reading comprehension requires knowledge â&#x20AC;&#x201C; of words and the world. Am Educ 2003;27(1):10-29. 23. Furnham A, Lane S. Actual and perceived attitudes towards deafness. Psychol Med 1984;14(2):147-123. 24. Faculty of Medicine and Health Sciences. Graduate attributes. Centre for Health Professions Education (CHPE), Stellenbosch University. 2013. http://www.sun.ac.za/english/faculty/healthsciences/Pages/Teaching---Learning.aspx?TermStoreId=d4aca01e-c7ae-4dc1-b7b2-54492a41081c&TermSetId=e4c997b1-09db-4950-862fac7f223a7185&TermId=b53b4d83-2487-46c1-a00d-ffe0e689ce2e (accessed 27 February 2018). 25. Cawthon SW, Winton SM, Garberoglio CL, Gobble ME. The effects of American sign language as an assessment accommodation for students who are deaf or hard of hearing. J Deaf Stud Deaf Educ 2011;16(2):198-211. https:// doi.org/10.1093/deafed/enq053 26. Qi S, Mitchell RE. Large-scale academic achievement testing of deaf and hard-of-hearing students: Past, present and future. J Deaf Stud Deaf Educ 2012;17:1-18. https://doi.org/10.1093/deafed/enr028 27. Convertino C, Borgna G, Marschark M, Durkin A. World and world knowledge among deaf learners with and without cochlear implants. J Deaf Stud Deaf Educ 2014;19(4):471-483. https://doi.org/10.1093/deafed/enu024 28. Goldin-Meadow S, Mayberry RI. How do profoundly deaf children learn to read? Learn Disabil Res Pract 2001;16:221-228. https://doi.org/10.1002/9780470757642.refs

Accepted 14 September 2017.

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Research

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

The perspectives of South African academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training S M Govender, MComm Path (UKZN), M Mars, MB ChB (UCT) Department of TeleHealth, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa Corresponding author: S M Govender (Samantha.govender@smu.ac.za)

The professional training and development of healthcare professionals in the area of telehealth is important to ensure the sustainability of this service delivery model. Tertiary institutions are among the key constituents involved in telehealth education, training and development. Academics within the healthcare sciences should therefore have the necessary experience and knowledge in this area to support the education and training of students. The objectives of this study were to determine the perspectives, experiences and attitudes of South African academics within various disciplines of health sciences regarding telehealth, as well as their views on suitable content areas for a telehealth module. A descriptive survey design was implemented. Sixtysix fulltime employed academic staff from five universities participated. The majority of participants were familiar with the terms telehealth/electronic health (eHealth), while 59% were unfamiliar with terms such as synchronous and asynchronous services. Eighty percent of respondents felt it necessary to include telehealth in the curriculum. The majority (89%) did not conduct research in telehealth. Seventy-one percent felt positive that telehealth could benefit the profession, and 30% stated that lack of standards creates a negative attitude toward the area and its sustainability. The majority of participants (77%) felt that their final-year students knew very little about telehealth upon exiting their study programme. Almost half (45%) of the participants felt that ethical issues were the most important aspect that needed to be included in a telehealth module, while data management was ranked as being least important (49%). The correlation between the perspectives on ethical issues and limitations to telehealth was statistically significant (p=0.007), implying that participants saw lack of ethical considerations as a limitation to the uptake of telehealth practice. While attitudes regarding telehealth were positive, concerns were raised around the lack of standards and guidelines. Opportunities for professional development in telehealth need to be created through continued professional development (CPD) workshops and training. This in turn may provide more skilled faculty to teach in this area, allowing students to receive better instruction on telehealth service delivery models. Afr J Health Professions Educ 2018;10(1):38-43. DOI:10.7196/AJHPE.2018.v10i1.957

The words telemedicine and telehealth are used synonymously by some. Telemedicine refers to the use of information and communication technologies for clinical diagnosis and monitoring and the provision of healthcare over distance, but telehealth is a broader concept. Telehealth is defined by the Health Resources and Services Administration[1] as â&#x20AC;&#x2DC;the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administrationâ&#x20AC;&#x2122;. Telehealth has been viewed as a promising method of addressing the current health challenges surrounding service delivery to remote and rural areas. It can be used to alleviate the shortage of healthcare practitioners; improve access to specialist physicians; reduce the costs of accessing healthcare services by reducing the need to travel for consultation; and provide support to rural general practitioners and community service therapists, thereby improving retention in rural communities.[2-6] One of the suggested strategies to promote telehealth at a national level within developing countries is to introduce telehealth into the education and training programmes of healthcare professionals, both undergraduate and postgraduate, so that they are aware of, and can use, telehealth methods to provide healthcare to their patients.[7] The benefits associated with telehealth provide impetus for student and professional training across the

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healthcare disciplines. As students receive their training from academics at tertiary institutions, trained faculty with relevant content knowledge[8,9] and research experience in the field[10] should be available to disseminate this information and to demonstrate how telehealth can be used to provide and improve patient care. A lack of skilled personnel to facilitate training of healthcare professionals is a barrier to sustaining telehealth models of service delivery.[11] A study on telehealth in primary care found that telehealth could support the primary healthcare approach, as its inclusion into student training can be used to connect students with patients from remote and rural areas, allowing them access to diverse communities, but also that insufficient training and exposure during undergraduate training contributed to a limited uptake of this technology.[12] These results are especially relevant in South Africa (SA), where almost 50% of the population lives in rural areas.[13] There is sufficient evidence supporting the use of telehealth services to improve patient care across many disciplines of health, including medicine, physiotherapy, nursing, audiology and speech-language pathology.[6,14-19] However, there is a paucity of literature pertaining to the training and education of students in using and implementing telehealth services. A systematic review conducted by Edirippulige and Armfield[20] found no record of education and training programmes on telehealth in Africa. This

Research is of concern, as the importance of telemedicine has long been recognised by the SA government. The first phase of the SA National Telemedicine System was implemented in 1999, but was not successfully sustained.[21] Healthcare acts and policies within SA recognise the value of information and communication technology (ICT) in health, and support the use of telehealth applications and technology within the healthcare service delivery model.[22-24] The National Department of Health outlines 10 priorities (the 10-point plan) within the national service delivery agreement, one of which is the need to improve health infrastructure, including the use of ICT and sophisticated technology to advance patient care, and has developed a National eHealth Strategy.[22] One aspect identified within the strategic objectives is the need to improve telehealth capacity building. The strategy notes that educational opportunities in telehealth are limited, and government therefore aims to promote capacity development in telehealth through education and research. Universities, through their academic staff, have been identified as key role-players to facilitate this process. Related to this is the development of education and training courses that are well structured, to provide the theoretical and practical competencies required for administering clinical and educational services via a telehealth model. In order to capacitate academics to teach and train students in this area, key aspects relating to telehealth need to be understood. A review of the literature identified key knowledge areas required for effective telehealth practice that should be included in a telehealth course: computer competence and literacy;[3,25,26] understanding of ethical and legal issues;[25-29] understanding of the protocols and standards that guide good practice;[30] and data management, specifically relating to online transmission, retrieval and storage of data.[29] It is important to put these issues into the SA context in view of current healthcare constraints, service delivery issues and the infrastructure requirements of a telehealth service. Early literature from the developed world found that some disciplines of healthcare reported limited or no exposure to telehealth during their undergraduate training. In 2002, the American Speech and Health Association found that only 11% of the 1 667 American speech language pathologists and audiologists used telehealth in their practice. Lack of theoretical and clinical exposure to telehealth at undergraduate level, lack of guidelines and insufficient clinical evidence were cited as the primary reasons for non-use by over three-quarters of respondents.[31] The current situation in SA is believed to be similar. The perspectives, practices and overall attitudes of academics toward education and training in telehealth is considered a key enabler of sustainable development of telehealth.[32] The aim of this study was to determine the perspectives, attitudes and exposure of academics within the various disciplines of the health sciences to telehealth and its inclusion in student training. The study further aimed to identify telehealth information that exists within the current curricula as well as to understand which areas of telehealth academics consider important when designing a telehealth course.

Methods

Ethical approval to conduct the study was obtained from the University of KwaZulu-Natal Ethics Committee (ref. no. HSS/0335/014D). A descriptive survey design was implemented, with quantitative methods of analysis. The questionnaire developed by the American Speech and Hearing Association[31] was adapted to include questions relevant to the SA context.

The questionnaire comprised 30 questions across four domains linked to the objectives of the study, which were to determine SA academicsâ&#x20AC;&#x2122;: (i) experiences (in teaching, learning and research) with telehealth; (ii) attitudes about telehealth; and (iii) perspectives on what they considered would be most valuable for inclusion in a telehealth course, based on six key areas provided. The questionnaire was circulated electronically via Google forms. Questions and statements were multiple choice, yes-or-no responses or open-ended, allowing participants to explain their responses. Letters requesting participation were sent to the seven SA universities offering health sciences programmes, of which five consented to participate in the study. Once institutional permission from the university was granted, permission from heads of department (HODs) of the various disciplines was requested. Some HODs failed to respond to the request, and this contributed to a low response rate. Invitations to participate in the study could only be sent to the list of email addresses that could be obtained from the HODs who furnished this information. An information letter together with a consent form and a link to the questionnaire was emailed to 170 academic staff members within health sciences departments from the five participating universities. The online survey system allowed the participants 3 weeks to respond. In addition to basing our questionnaire on one that had already been developed and used, other measures to ensure the validity of our questionnaire included a pilot study. Ten part-time employed academics were asked to complete the questionnaire to discover whether they experienced any problems answering any of the questions. They were required to complete a response form giving feedback on the clarity of questions, language and grammar, as well as on the length of the questionnaire. No-one experienced any challenges, and no changes were made to the questionnaire. The data were analysed using descriptive and inferential statistics. For the 6-point Likert-scale questions on key areas that could be included into a telehealth module, Spearmanâ&#x20AC;&#x2122;s correlation coefficient was calculated. The mean square contingency coefficient, the phi coefficient, was used to determine the degree of association between the binary variables (yes-or-no responses). Alpha was set at 5%.

Results

A total of 66 academics completed the questionnaire, a response rate of 39%. The distribution of participants across the various health science disciplines is shown in Fig. 1. Twenty-nine of the academics (44%) had >10 years of teaching experience, 19 had <5 years of experience (29%) and the remaining 18 had between 5 and 10 years of experience (27%).

Experience with and exposure to telehealth (teaching, learning and research) Participants were asked about their experiences with, and exposure to, telehealth. The questions related to their understanding of key definitions and operation and familiarity with telehealth equipment, and their involvement in teaching and research within these areas. Regarding how they were first introduced to telehealth, 51 respondents (77%) indicated that they had read about it, while 9 (14%) had heard about it during a conference presentation. The remainder were introduced to it by colleagues

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Research

11% 4% 27% 8%

9% 12% 14%

Audiology Speech language pathology Occupational therapy Physiotherapy Human nutrition and dietetics Public health and nursing Unknown Medicine

15%

Fig. 1. Distribution of participants by discipline, %.

One person who felt that it was unnecessary to include telehealth in the curriculum, however, added: ‘Our students are being trained to be clinicians and not academics, the use of telehealth between client and clinician is not relevant in our underresourced areas … among clinicians it is used, and can be learnt in the field at the particular venue, and hence does not to be included in the curriculum’ (occupational therapist, 7 years’ experience). With regard to devices and technology, all institutions had some form of telehealth equipment across the various disciplines. The three disciplines reporting the most access to technology and devices were audiology, physiotherapy and nursing. Three of the five institutions owned a Kudu-wave 5 000 tele-audiology device. One institution is involved in mHealth (mobile health) and has developed a smartphone application for hearing screening.

Table 1. Experiences with and exposure to telehealth (teaching, learning and research) (N=66) Familiarity with basic telehealth terminology Familiarity with synchronous v. asynchronous telehealth services Attended a CPD-related activity on telehealth Experience with operating a telehealth device Researching telehealth Teaching telehealth Do you think telehealth should be included in the curriculum?

Yes, n (%) 59 (89) 27 (41) 18 (27) 26 (39) 7 (11) 14 (21) 53 (80)

No, n (%) 7 (11) 39 (59) 48 (73) 40 (61) 59 (89) 52 (79) 10 (15)

Unsure

3 (5)

CPD = continuing professional development.

and demonstrations conducted by suppliers. Responses to the yes-or-no options are shown in Table 1. The majority of the academics did not teach (79%) or research (89%) telehealth. There was a statistically significant relationship between teaching and research (p=0.001), as those who were teaching telehealth were also conducting research in the area. The majority (80%) of participants indicated that they felt it is necessary to include telehealth in the curriculum, while some were either unsure or disagreed. An open-ended question asked them to support their response. Most attributed their reasoning to meeting the needs of communities through the use of telehealth services, and 35 (53%) participants stated that students need to have knowledge, exposure and competence in this area so that it is sustainable. One participant stated: ‘The times that we live in are changing and platforms for service delivery are also changing. Students should be able to function in various contexts and use various platforms to offer services to patients. I think understanding tele-audiology will be beneficial to students, especially taking into consideration the shortage of professionals in SA’ (audiologist and speech-language pathologist, 8 years’ experience). The importance of using internet-based services was emphasised: ‘ Telehealth is a collection of means or methods for enhancing healthcare, public health, and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health and education services. I believe that content is freely available to all via the internet and it is best to incorporate it into teaching rather than avoid it’ (physiotherapist, 5 years’ experience).

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The discipline of nursing across two institutions reported management of rural community patients via telehealth services.

Attitudes towards and perspectives on telehealth

A total of 47 (71%) respondents indicated that they felt that telehealth could positively benefit their profession, and 47 (71%) stated that it has the potential to address service delivery barriers. Twenty (30%) stated that the lack of standards for telehealth practice creates a negative attitude towards the area, while 11 (17%) had a negative attitude regarding the sustainability of telehealth practices even though they felt positive about the benefits. A total of 46 (70%) felt that introducing content on telehealth-based teaching resources could improve overall teaching and learning. However, 18 (27%) did not feel that introducing it would improve learning outcomes for their respective degrees. The responses to the other statements are shown in Table 2. There was no correlation between responses to the question, ‘Can telehealth positively impact the profession?’ and the question on lack of standards (p=0.369). This implies that not all participants who felt that the lack of standards, guidelines and policy makes it difficult to implement telehealth thought that this would interfere with the positive impact that telehealth could make on their profession. Additional comments regarding their attitudes towards telehealth were sought, and included the following: ‘More information and practical demonstrations may change negative views of most audiologists, including academics, toward tele-audiology’ (audiologist, 20 years’ experience). ‘I don’t know much about tele-audiology currently and would benefit from knowing more’ (audiologist and speech-language pathologist, 8 years’ experience).

Research ‘ It is unrealistic at most district-level facilities around our country, and so will students actually be able to use or benefit from this while studying or when qualified?’ (occupational therapist, 1 year’s experience). ‘I believe in its potential to resolve many of the practical issues we experience in training interns (human nutrition and dietetics, 20 years’ experience). Respondents were asked whether they thought that telehealth-based services would be a feasible way of ensuring that students have adequate

central to their profession and their selection of ethical issues as most relevant was also significant (p=0.04).

healthcare professionals. The key findings of this study are that the majority of participants do not have much experience with or knowledge about telehealth, do not include any telehealth content in their teaching, have not used a telehealth device and do not have any current research interests in this area. This relationship between teaching and research in telehealth was significant, implying that those participants who were teaching in the area were also engaged in research, possibly as a way to advance their knowledge. The academics’ lack of knowledge about telehealth makes it difficult for them to teach in

Discussion

Telehealth can improve service delivery to remote and rural areas, reduce health service disparities that exist between socioeconomic groups and reduce health costs. Education and training in this area would strengthen the health system’s capacity to deliver and sustain these services.[20] Academics are central in facilitating the education and training of undergraduate

Table 2. Attitudes regarding telehealth (N=66) Yes, n (%) 47 (71) 20 (30) 10 (15) 47 (71) 47 (71) 50 (76) 32 (48) 18 (27)

Statement Telehealth can positively impact our profession Lack of standards, guidelines and policy makes it difficult to implement such practice Face-to-face contact is central to our professional interaction, making tele-audiology inappropriate Telehealth can address the barriers to services related to access and language between clinician and patient Telehealth can improve health service delivery in SA Telehealth is a promising concept, provided that a structured curriculum is designed to train students appropriately I think that telehealth is sustainable within the SA context Introducing telehealth into clinical training would improve learning outcomes by increasing exposure to more diverse patients

No, n (%) 19 (29) 46 (70) 56 (85) 19 (71) 19 (71) 16 (24) 34 (52) 18 (27)

SA = South Africa.

49 45

Participants who chose ranking, %

30 26

25 23 21

21 18

18 15

13 13 8 5 5

8 5

3 0

en t em ag an Da ta M

lic SA abil co ity nt to ex t

Ap p

d Com te p ch u . c ter om li pe tera te cy nc e

su es l is ca Et hi

te L leh im ea ita lth tio se ns rv of ice s

da pr rds ot an oc d ol s

13 10

St an

exposure to a maximum number and variety of patients, of whom 55 (83%) agreed. When asked whether their students were knowledgeable about telehealth services, 51 (77%) felt that their students knew very little about them. Only 14 (21%) indicated that the introduction of telehealth modules was discussed in curriculum planning meetings. Finally, academics were asked to rank, in order of importance from most important to least important, the six content areas considered relevant for a telehealth module identified from the literature. These were: standards and protocols; ethical issues; computer literacy and understanding of computers and technology; limitations of telepractice; telepractice as it relates to the SA and African context; and data management as it relates to online service delivery. Only 54 participants responded to this question in full (Fig. 2). A significant correlation was noted between the variables ‘ethical issues’ and ‘limitations of telehealth services’ (p=0.007). Respondents who regarded ethical issues as most or very important also regarded limitations of telehealth services to be very important or important. The correlation between individuals’ responses to the question regarding how face-to-face contact is

Content areas Most imp. for me

Very imp.

Imp.

Good to include

Include if there's time

Least imp. to me

Fig. 2. Participant rankings of importance (imp.) of six content areas for a telehealth module (6-point Likert scale).

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Research this area. This finding supports a recent study by Grogan-Johnson et al.,[29] who surveyed telepractice training in graduate speech-language pathology and audiology programmes. The barriers to adopting telepractice in graduate programmes were related to, among others, a lack of trained faculty to provide instruction. Ehnfors and Grobe[33] describe this as a real challenge facing healthcare professionals who may find themselves in the future working in a technologically driven healthcare system without the necessary competencies. These studies provide strong motivation for education and training, and demonstrate the need for certification programmes for both academics and healthcare professionals, so that students can also be the recipients of this information. Although the majority of academics displayed a positive attitude towards the impact that telehealth can make on the profession, and on the improvement of service delivery, the lack of available standards and guidelines created a negative attitude towards it. Picot[25] emphasises the need for guidelines and standards to be developed across all professions that intend using telehealth systems and methods, and further recommends that education and training standards be developed so that suitable knowledge and skills can be obtained. A systematic review by Molini-Avejonas et al.[34] identified the barriers to the use of telehealth in the speech, language and hearing sciences as the lack of training, regulation of practice and acceptance and recognition of telehealth benefits by both the public and professionals. These findings further support the need for training and development in the area of telehealth. In an article by Frenk et al.[35] on transforming education for health professionals to strengthen health systems, it was emphasised that ICT is important for transformative learning in terms of exposing undergraduates to telehealth models of service delivery. The authors state that ‘an exciting area of development is the application of ICT to build global consortia of education and institutions to leverage their resources, realise synergies and transform educational opportunity into a global public good’. A survey of the attitudes of 202 audiologists toward tele-audiology identified interest in using internet-based facilities to provide patient support. However, participants had concerns regarding their lack of knowledge of and exposure to technologically based services during their undergraduate years.[36] The literature also shows that a lack of user acceptance of technology is a primary reason for the poor uptake of telehealth.[37,38] Other studies suggest that exposure to and experience with telehealth increases positivity.[36,39] The present study reflects an overall lack of experience with and exposure to telehealth in SA academics. In addition, participants demonstrated varied attitudes regarding the feasibility and sustainability of telehealth within their contexts. This attitudinal disposition could shape learners’ interest and practice within the area. The majority of participants did not feel confident in the subject matter, owing to their lack of exposure to it. A way forward in addressing this would be to promote professional development activities in the area of telehealth. Various systematic reviews indicate that across the different health science disciplines, there are needs for protocol and guideline development, increasing confidence and competence, and the development of training standards.[25,29,40,41] This is in keeping with the strategic priorities of the SA government, in terms of the eHealth strategy for SA.[22] According to the World Health Organization,[42] health professionals and academic institutions are among the key constituents involved in addressing the health needs of communities, through evidencebased teaching and the development of new and improved methods of service delivery.[42]

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For the purposes of the study, six key areas were suggested as potential content areas for a telehealth module. Protocol and standards development was ranked as the most important area by participants. This was seen to be one of the key strategies necessary for promoting the advancement of telehealth in various health disciplines, as well as for interprofessional collaboration.[43] Wade et al.[44] have also identified the development of protocols as one of the key components of sustainable practice. Contextual relevance is important within healthcare, especially when one considers establishing infrastructure and rolling out technology to promote health services. In a context where social determinants of health have contributed to the inequitable distribution of health resources and access,[45] and to failure in redressing the injustices of the past, careful consideration must be taken to ensure that these service delivery models are both feasible and sustainable. Respondents did not feel that contextual relevance was an important component of a telehealth module, with 49% stating that it can be included if there is time. Data management was viewed as the least important subject to be included in a telehealth module. However, data management is a very important part of telehealth services, especially when one considers the intricacies involved in the storage, retrieval and transmission of patient information. Failure to adequately manage patient data could result in malpractice. Data management was, however, ranked as the least important component by 49% of respondents. An understanding of the legal and ethical issues related to telehealth service delivery is crucial for effective practice.[27] Ethical practice guides professional behaviour, and is central to service delivery. Its importance was reflected in the responses, with 45% rating it as the most important component of a telehealth module, and 21% as very important. A significant correlation was noted between the variables ‘ethical issues’ and ‘limitations’, as well as between face-to face-contact and ethical practice. This implies that participants considered the limitations of telehealth practice and face-toface contact with patients as important ethical considerations. According to Hebert et al.,[46] an understanding of technology, together with its advancement and development, is absolutely integral in promoting the progression of the science behind telehealth. They emphasise that it is important to also understand how the patient views technology and its ability to assist them in healthcare. This understanding is largely developed from the information imparted by a knowledgeable healthcare provider. Understanding how technology works is important, considering that telehealth technology can range from simple videoconferencing technology to sophisticated computer programs and virtual environments.[47] Jobson[48] mentions that while the government in the USA has significantly progressed in providing medical technology and information systems to support the healthcare system, a lack of trained professionals has resulted in its underutilisation. Computer literacy and competence in using technology was ranked third of the six components. The limitations of this study were the refusal of two universities to participate, and the small sample size, representing less than 50% of medical staff at the five participating universities, therefore limiting the generalisability of study findings. The requirement to rank the six content areas on an ordinal scale of importance may give a skewed impression of the overall view of the respondents. The relative differences in importance are not known. Some respondents, for example, may have considered two or more components to be of very similar importance, but were obliged to rank them.

Research Conclusion

The role of academia within telehealth education and training is emphasised in the literature, and relates to the need for its inclusion in teaching and clinical training for its sustainability. Academics in this study shared the view that the inclusion of telehealth in the curriculum could be beneficial for students, and for their own development. They also considered the development of standards and protocols and legal and ethical issues as the most important areas to include in a telehealth course, while applicability to the SA and African context and data management were viewed as the least important considerations. A dialogue needs to begin among the various disciplines on how to integrate telehealth knowledge and clinical training into their curricula. Academics are at the forefront of providing knowledge to students, but can only do so if they are knowledgeable themselves. It would also be valuable for more research to be conducted within individual health professions regarding the clinical implications of introducing telehealth into curricula. This will increase knowledge production, which could lead to knowledge translation, thus ultimately addressing the knowledge-to-action gap. This study also highlights the need to develop training standards and guidelines for telehealth. Guidelines – clinical, technical, operational and ethical – are required to ensure quality of care and to overcome current negative perceptions of telehealth. Professional development in the area of telehealth for academics is also required, and can be facilitated through more workshops, conference presentations given by experts in the field and demonstrations by companies selling telehealth systems. The future of telehealth services depends largely on the pursuit of high-quality training and development, as it is difficult to envisage the use of technologically based healthcare without transforming the training of healthcare professionals. 1. Health Resources and Services Administration. Defining Telehealth in Policy. https://www.hrsa.gov/sites/default/ files/hrsa/advisory-committees/rural/publications/2015-telehealth.pdf (accessed 4 June 2017). 2. Bonney A, Knight-Billington P, Mullan J, et al. The telehealth skills, training and implementation project: An evaluation protocol. JMIR Res Protoc 2015;4(1): e2. https://doi.org/10.2196/resprot.3613 3. Carter L, Horrigan J, Hudyma S. Investigating the educational needs of nurses in telepractice: A descriptive exploratory study. J Univ Contin Edu 2010;36(1):1-20. https://doi.org/10.21225/D5RP4B 4. Givens GD, Elangovan S. Internet applications to tele-audiology – nothing but net. Am J Audio 2003:12(2);59-65. 5. Yao J, Yao, D, Givens GD. A browser-server-based tele-audiology system that supports multiple hearing test modalities. Telemed E Health 2015;21(9):697-704. https://doi.org/10.1089/tmj.2014.0171 6. Swanepoel DW, Olusanya BO, Mars M. Hearing healthcare delivery in sub-Saharan Africa – a role for teleaudiology. J Telemed Telecare 2010;16(2):53-56. https://doi.org/10.1258/jtt.2009.009003 7. Edirippulige S, Armfield, NR, Smith A. A qualitative study of the careers and professional practices of graduates from an e-health postgraduate programme. J Telemed Telecare 2013;18(8):455-459. https://doi.org/10.1258/jtt.2012. gth107 8. Rena, U. Who will teach: A case study of teacher education reform. San Francisco: Caddo Gap Press, 2000. 9. Rice JK. Teacher quality: Understanding the effectiveness of teacher attributes. Washington, DC: Economic Policy Institute, 2003. 10. Shulman LS. Those who understand: Knowledge growth in teaching. Edu Res 1986;15(2):4-14. 11. Conde JG, De S, Hall RW, Johansen E, Meglan D, Peng GC. Telehealth innovations in health education and training. Telemed J E Health 2010;16(1):103-106. https://doi.org/10.1089%2Ftmj.2009.0152 12. Flynn D, Gregory P, Makki H, Gabbay M. Expectations and experiences of eHealth in primary care: A qualitative practice-based investigation. Int J Med Inform 2009;78(9):588-604. https://doi.org/10.1016/j.ijmedinf.2009.03.008 13. Statistics South Africa. Technical report. Community survey 2016. http://www.statssa.gov.za/?p=9922 (accessed 4 June 2017). 14. Bashshur RL. Telemedicine and health care. Telemed J E Health 2002;8(1):5-12. https://doi. org/10.1089/15305620252933365 15. Boots RJ, Singh S, Terblanche M, Widdicombe N, Lipman J. Remote care by telemedicine in the ICU: Many models of care can be effective. Cur Opin Crit Care 2011;17(6)634-640. https://doi.org/10.1097/ MCC.0b013e32834a789a 16. Jin, C, Ishikawa A, Sengoku Y, Ohyanagi, T. A telehealth project for supporting an isolated physiotherapist in a rural community of Hokkaido. J Telemed Telecare 2000;6(Supp 2):S35-S37.

17. Tousignant M, Moffet H, Cabana F, Simard J. Patients’ satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists’ satisfaction toward technology for post-knee arthroplasty: An embedded study in a randomized trial. Telemed J EHealth 2011;17(5):376-382. https://doi.org/10.1089/ tmj.2010.0198 18. Dansky KH, Joseph V, Bowles K . Use of telehealth by older adults to manage heart failure. Res Gerontolog Nurs 2008;1(1):25-32. https://doi.org/10.3928/19404921-20080101-01 19. Fu S, Theodoros DG, Ward EC. Delivery of intensive voice therapy for vocal fold nodules via telepractice: A pilot feasibility and efficacy study. J Voice 2015;29(6):696-706. https://doi.org/10.1016/j.jvoice.2014.12.003 20. Edirippulige S, Armsfield NR. Education and training to support the use of clinical telehealth: A review of the literature. J Telemed Telecare 2016;23(2):273-282. https://doi.org/10.1177/1357633X16632968 21. Mars M. Tele-education in South Africa. Frontiers Pub Health 2014;2(173):1-10. https://doi.org/10.3389/ fpubh.2014.00173 22. Department of Health, South Africa. eHealth strategy for SA (2012 - 2016). Pretoria: NDoH, 2012. http://www. health-e.org.za/wp-content/uploads/2014/08/South-Africa-eHealth-Strategy-2012-2017.2012.pdf (accessed 3 August 2016). 23. South Africa. National Health Act No. 61 of 2003. 24. Government of South Africa. Negotiated Service Delivery Agreement for Outcome 2. A Long and Healthy Life for All South Africans, 2010. Pretoria: Government Printer, 2010. http://www.kznhealth.gov.za/summit/outcome2.pdf (accessed 4 June 2016). 25. Picot J. Meeting the need for educational standards in the practice of telemedicine and telehealth. J Telemed Telecare 2000;6(2):59-62. https://doi.org/10.1258/1357633001935608 26. Lamb GS, Shea K. Nursing education in telehealth. J Telemed Telecare 2006;12(2):55-56. http://doi. org/10.1258/135763306776084437 27. George C, Whitehouse D, Duquenouy P. eHealth: Legal, Ethical and Governance challenges. Berlin, London: Springer, 2013. 28. Fleming DA, Edison KE, Pak H. Telehealth ethics. Telemed J e-Health 2009;15(8):797-803. https://doi.org/10.1089/ tmj.2009.0035 29. Grogan-Johnson S, Meehan R, McCormick K, Miller N. Results of a national survey of preservice telepractice training in graduate speech-language pathology and audiology programs. J Contemp Issues Commun Sci Disord 2015;42:122-137. http://doi.org/1092-5171/15/4201-0122 30. Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patient care. Lancet 2003;362(9391):1225-1230. https://doi.org/10.1016/S0140-6736(03)14546-1 31. American Speech-Language-Hearing Association. Survey Report on Telepractice Use among Audiologists and Speech-Language Pathologists. https://www.asha.org/uploadedFiles/practice/telepractice/SurveyofTelepractice.pdf (accessed 20 March 2016). 32. Dean CM, Stark AM, Gates CA, et al. A profile of physiotherapy clinical education. Aus Health Review 2009;33(1):38-46. Dean CM, Stark AM, Gates CA, et al. Profile of physiotherapy clinical education. Aus Health Review 2009;33(1):38-46. https://doi.org/10.1071/AH090038 33. Ehnfors M, Grobe SJ. Nursing curriculum and continuing education: Future directions. Int J Med Inform 2004;73(78):591-598. https://doi.org/10.1016/j.ijmedinf.2004.04.005 34. Molini-Avejonas DR, Rondon-Melo S, Amato CA, Samelli AG. A systematic review of the use of telehealth in speech, language and hearing sciences. J Telemed Telecare 2015;21(7):367-376. https://doi.org/10.1177/1357633X15583215 35. 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 36. Singh G, Pichora-Fuller MK, Malkowski M, Boretzki M, Launer S. A survey of the attitudes of practitioners toward teleaudiology. Int J Audiol 2014;53(12):850-860. https://doi.org/10.3109/14992027.2014.921736 37. Nwabueze SN, Mesa NP, Kifle M, Okol C, Chustz M. The effects of culture of adoption of telemedicine in medically underserviced communities. Proceedings of the 42nd Hawaii international conference on system sciences, 5 - 8 January, 2009. Washington, DC: USA, IEEE Computer Society, 2009. https://doi.org/10.1016/j.ijmedinf.2006.05.041 38. Pagliari C, Sloan D, Gregor P, et al. What is eHealth: A scoping exercise to map the field. J Med Int Res 2005;7(1):201210. https://doi.org/10.2196%2Fjmir.7.1.e9 39. Hanson D, Calhoun J, Smith D. Changes in provider attitudes toward telemedicine. Telemed J E Health 2009;15(1):39-43. https://doi.org/10.1089/jmi.2008.0052 40. Mahomed F, Swanepoel DW, Eikelboom RH, Soer M. Validity of automated threshold audiometry: A systematic review and meta-analysis. J Ear Hearing 2013;34(6):745-752. https://doi.org/10.1097/AUD.0b013e3182944bdf 41. Govender SM, Mars M. The use of telehealth services to facilitate audiological management for children: A scoping review and content analysis. J Telemed Telecare 2017;23(3):392-401. https://doi.org/10.1177/1357633X16645728 42. World Health Organization. Cited in Telemedicine: Opportunities Member States, 2012: Report on the Second Global Survey on eHealth 2009 (Global Observatory for eHealth Series, Volume 2). Geneva: WHO, 2012. http:// www.who.int/goe/publications/goe_telemedicine_2010.pdf (accessed 10 August 2016). 43. Jarvis-Selinger S, Chan E, Payne R, Plohman K, Ho K. Telemed J E Health 2008;14(7):720-725. https://doi. org/10.1089/tmj.2007.0108 44. Wade VA, Eliott KA, Hiller JE. Clinician acceptance is the key factor for sustainable telehealth services. Qual Health Res 2014;24(5):682-694. https://doi.org/10.1177/1049732314528809 45. McLaren Z, Ardington C, Leibbrandt M. Distance as a barrier to healthcare access in South Africa. A South African labour and development research unit (SALDRU) working paper (97). Cape Town: SALDRU, University of Cape Town, 2013. 46. Hebert MA, Korabek B, Scott R. Moving research into practice: A decision framework for integrating home telehealth into chronic illness care. Int J Med Inform 2006;75(12):786-794. https://doi.org/10.1016/j.ijmedinf.2006.05.041 47. Karr S. Getting to know telepractice. The ASHA leader. 2012;17(30):30-30. https://doi.org/10.1044/leader. SCM.17122012.30 48. Jobson M. Structure of the health system in South Africa. Khulumani Support Group, 2015. https://webcache. googleusercontent.com/search?q=cache:OVSLA4BECq0J:https://www.khulumani.net/active (accessed 2 August 2016).

Accepted 15 August 2017.

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Research

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

Comparing international and South African work-based assessment of medical internsâ&#x20AC;&#x2122; practice K L Naidoo,1,2 MB ChB, DCH, FCPaed; J van Wyk,3 BSc Ed, BEd, MEd, PhD; M Adhikari,2 MB ChB, FCPaed, PhD 1

King Edward VIII Hospital, KwaZulu-Natal Department of Health, Durban, South Africa

Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Department of Clinical and Professional Practice, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: K Naidoo (naidook9@ukzn.ac.za)

Background. Resource constraints and a high disease burden impact on the work-based assessment (WBA) of medical interns in South Africa (SA). Objectives. To review the use of workplace-based assessment frameworks in intern practice in SA and to compare these with international practices. Methods. A systematic review using a thematic analysis was performed to analyse 97 articles selected from an initial scoping of 360 sources of evidence on WBA in internship between 2000 and 2017. This process informed a synthesis of descriptive and analytic themes related to competency-based assessment practices relevant to internship in SA. Results. There was an overall dearth of studies on assessment of medical interns in lower-middle-income countries (LMICs). The context in which the assessment of interns in SA occurs has many challenges related to resources, workload and supervision. SA intern assessment is largely focused on core clinical competency, and this occurs without using competency-based frameworks. This focus was reflected in the finding that most studies in SA have dealt with the assessment of core procedural skills related to acute clinical care, while the assessment of non-clinical competencies and non-procedural skills was poorly addressed. Self-assessment by interns was the predominant strategy used in the SA context. The review revealed limitations in the use of multiple assessment strategies and direct observation in the local context, in contrast to practices in most high-income countries. Conclusions. A shift in focus to assess both procedural and non-procedural skills within a competency-based framework is advocated for SA internship, together with the use of multiple assessment tools and strategies that rely on direct observation of performance. Afr J Health Professions Educ 2018;10(1):44-49. DOI:10.7196/AJHPE.2018.v10i1.955

Internship following graduation is an essential period for junior doctors to develop their skills and apply their knowledge in the context of the local health system. Newly qualified medical doctors in South Africa (SA) enter a supervised 2-year internship period requiring learning and service delivery to occur concurrently in a work-based setting. Work-based assessment (WBA) during internship is integral to identifying underperformance and to informing decisions regarding certification for independent, unsupervised practice.[1] WBA is a complex process that should include the assessment of multiple competencies using validated methods and tools that accurately reflect performance. The assessment process aims to ensure that doctors perform as competent, ethical practitioners who have â&#x20AC;&#x2DC;globally connected, locally responsive attributes that are population and patient-centredâ&#x20AC;&#x2122;.[2] Research into effective WBA practices has led to advances in understanding the optimal ways to assess interns.[3] Many of these innovations in WBA have, however, not yet been translated into practice in many lower-middleincome countries (LMICs) such as SA.[4] Internship training in SA, as in many other LMICs, occurs within a resource-constrained workplace setting where high patient-doctor ratios are the norm.[2] The high rate of needlestick injuries in an HIV-burdened context, coupled with long working hours, has resulted in high levels of stress and burnout among interns in SA.[5] Additional factors impacting negatively on intern training include poor institutional leadership and an inability to recruit, retain and develop appropriate staff.[6,7] There is an increasing number of reports of overburdened and inadequately

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experienced supervisors, which also influences the quality of internship training across institutions in SA.[8,9] The concurrent impact of inadequate supervision within poor working conditions has raised concerns about the quality of assessments of interns in this context.[5,8] The Health Professionals Council of SA (HPCSA) is the regulatory body responsible for the accreditation of institutions, supervisors, curricula and intern-assessment practice.[1] The HPCSA undertakes biannual accreditation visits to each institution to evaluate and ensure adherence to the mandated requirements for adequate training.[1] While a graduate competency framework derived from the Royal College of Physicians and Surgeons of Canada physician competency framework (CanMEDS) has been adopted by most undergraduate and many postgraduate medical training programmes in SA, this has not been rigorously applied to the internship period.[10] WBA in internship in SA is based around a logbook that includes discipline-specific competencies focusing on procedural skills and some non-procedural skills, including medical ethics. Checklists that rely on self-assessment by interns and inputs from their supervisors with regard to performance are included in the logbook for each discipline.[1] This study was conducted to analyse assessment practices within a competency-based framework in a resource-limited environment. This process can help to identify weaknesses, benchmark practices and inform decisions, in improving the assessment of interns in SA and in other LMICs.

Research Methodology

The literature review used a thematic analysis to synthesise findings on assessment practices within a competency-based framework among interns in SA, compared with international practice. Thematic analysis is often used to analyse data in primary qualitative research and can be used in systematic reviews to bring together and integrate the findings of multiple qualitative studies.[11] A thematic analysis was undertaken to review the studies, which included many diverse approaches to research. The aim of this research synthesis was to identify and highlight key concepts from literature sources and to recognise and compare the use of the same concepts in other studies.[12]

Search strategy

The initial scoping of the literature involved searches on electronic databases by the primary author and an assistant. The databases searched included: EBSCO HOST; Medline; PubMed; ERIC (Education Resources Information Centre); SABINET (SA Bibliographic Information Network) and Education Source. The terminology to describe a medical intern, i.e. a doctor in the first 2 years following undergraduate medical qualification, varies greatly. The terms commonly used include ‘medical intern’; ‘foundation year doctor’; ‘pre-registration house officer’ and ‘junior doctor’. In all databases searched, these terms were used as the primary search terms. The key words ‘assessment’, ‘assessment tools’, ‘competency’ and ‘competency framework’ were used in conjunction with the primary search terms. In addition to the articles obtained through various databases, articles were selected based on manual searches of references cited in key articles. Policy reviews, reports relating to assessment and evaluation of national intern programmes, stakeholder analyses, theses and conference proceedings were included in the secondary search. Fig. 1 indicates the process followed in the systematic literature review. English-language articles published between 2000 and 2017 were included for review. The last search was conducted at the end of January 2017. The articles selected for inclusion focused only on the WBA of junior doctors in their first 2 years post qualification (interns). Literature that included undergraduate medical students was excluded. Articles describing the assessment of first-year residents in specialty programmes in the USA were included, while those that focused on specialty programmes whose participants

were in the later years of specialisation (secondyear residents onwards) were excluded.

the researchers to reach consensus on the final descriptive themes.

Quality criteria

Data synthesis

Assessing the quality of the largely qualitative research studies that were identified was necessary to avoid drawing unreliable conclusions.[11] In our review, we assessed studies according to seven broad criteria:[13,14] the relevance of the study to the review question; the appropriateness of study design; transferability of the conclusions drawn; the use of context to enable comparability of the findings to interns in SA; data collection; analysis; and finally, an account of reflexivity, in terms of recognising personal biases.[14]

The synthesis took the form of three stages: line-by-line coding of the findings of primary studies; organisation of these ‘free codes’ into related areas to construct descriptive themes; and the development of analytical themes. A multidisciplinary review team consisting of the main author (an intern supervisor and clinician), the second author (the professional health educationist) and the third author (an academic experienced in postgraduate training) reviewed the data obtained to ensure its relevance and robustness in fulfilling the objectives of the review. The analytical themes were refined through a cyclical process with the primary author developing the first draft of inductive codes and two co-authors contributing to the refining and identification of the final themes. The final themes, chosen by consensus, were sufficiently comprehensive to describe the categories and to meet the primary objective of the review.[11,12]

Data extraction

All articles identified from the initial scoping of the literature were reviewed by the main author using the inclusion criteria stipulated.* Those studies identified after this process were subjected to a quality assessment, as indicated. Those studies that were identified following the quality assessment were scanned for key concepts, which were inductively coded and tabulated. A second independent investigator, a professional health educator, then reviewed the inductive codes to ensure concordance with the primary sources. The individually derived codes were subsequently discussed between

Results

The results from the literature searches indicated that the number and quality of research evidence on WBA during internship differed significantly between international and SA sources. A total of

Scoping Use search terms only

EBSCOhost, MEDLINE, PubMed, ERIC, SABINET, Education Source (N=360)

Inclusion/exclusion criteria Only studies on interns in first 2 years of training

High-income countries (USA, Canada, UK, NZ, Australia), n=241 LMICs, n=119 (inc. 19 from SA)

Excluded, n=178 Focused on undergraduate or postgraduate programmes Quality criteria 1. Relevance 2. Design 3. Transferability 4. Context 5. Data collection/ sample 6. Analysis 7. Reflexivity

Thematic analysis 1. Descriptive themes 2. Analytical themes

Total, n=182

SA, n=36

International, n=146

Excluded, n=85 Focused on learning environment

Included, n=97

SA, n=19

High-income countries, n=78

Fig. 1. Inclusion and exclusion criteria. (SABINET = South African Bibliographic Information Network; ERIC = Education Resources Information Centre; NZ = New Zealand; LMICs = lower-middle-income countries; inc. = including; SA = South Africa.)

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Research 67% percent of the initial 360 articles sourced from the primary searches were from high-income countries, i.e. the UK, North America (USA and Canada), Western Europe, Australia and New Zealand. Using the inclusion and exclusion criteria – selecting only studies involving newly qualified doctors in their first 2 years following graduation (interns) –182 articles were selected. Of these, 146 were from high-income countries, and 36 from SA. An application of the quality criteria revealed a large number of studies that did not meet the criteria, as they were not relevant to the research question.[13,14] As indicated in Fig. 1, many studies identified in our search on assessment among interns dealt largely with environmental factors, and not assessment within a competency framework. Only 19 SA articles had a primary focus on WBA in interns, while 78 articles from high-income countries focused on the objectives of the review.

Ninety-seven articles were thus finally included for analysis to identify definitive themes (Fig. 1). The review aimed to extract and synthesise findings relating to the use of competency-based assessment frameworks among interns in SA. There was a paucity of studies on competency-based assessment among interns in SA in comparison with the studies from high-income countries. The aim of the study was therefore to compare and report on similarities and differences in the WBA of medical interns across the two contexts. Tables 1 - 4 depict the major descriptive themes identified from the inductive codes, which were derived from the primary sources of literature, and the four analytical themes developed. These themes are ‘lack of competency-based frameworks in accrediting interns in SA’, ‘emphasis on assessing only clinical procedural skills instead of both clinical and

Table 1. Analytical theme 1: Lack of competency-based frameworks Inductive codes from primary sources 1. Defining competency-based systems 2. Reasons for shifting towards a competency-based system 3. Validation of competency tools using factor analysis and other methods 4. Defining specific competencies required by junior doctors 5. Limitations in competency-based assessments 6. A shift to the use of entrustable professional activities and milestones

Major descriptive themes

7. Rates of underperformance 8. Factors affecting underperformance among interns 9. Innovative and new methods of assessing ‘at-risk’ interns

Recognition of underperformance

Analytical themes

The use of a competency-based framework Lack of competency-based frameworks

Table 2. Analytical theme 2: Emphasis on assessing clinical procedural skills Inductive codes from primary sources 1. Procedural skills assessed: • Resuscitation • Obstetric and anaesthetic skills • Paediatrics • Surgical and related disciplines skills 2. Non-procedural skills: • Prescribing skills • Documentation of clinical events and procedures • Radiological assessment • Mental-state examinations

Major descriptive themes

Analytical themes

Type of skills being assessed

Emphasis on assessing clinical procedural skills

Table 3. Analytical theme 3: Self-assessment instead of direct observed assessment Inductive codes from primary sources • Evidence of the poor reliability of self-assessment tools • Poorly performing interns have poor ability in self -assessment • Aggregate self-assessment valid for programme evaluation • The use of log books or tick lists not a reliable tool for assessment • Portfolios are useful in assessing interns • • • • •

Multisource feedback tools used successfully among interns The use of mini-CEX (clinical evaluation exercise) The use of the mini-PAT (peer assessment tool) The use of the DOPS (directly observed procedural skills) The use of peer review tools

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Major descriptive themes

Analytical themes

The use of self-assessment

Self-assessment instead of direct observed assessment

The use of directly observed assessments

Research Table 4. Analytical theme 4: Impact of the learning environment Inductive codes from primary sources • Constant change as a norm of the intern working environment • Disease burdens of LMICs • Burnout • Workload as an aggravating factor in internship • Workhours in internship • Availability of resources in internship learning environment • Reliability and relevance of measuring intern preparedness • Trends in preparedness across disciplines and institutions • Factors influencing preparedness of interns • Linkages of preparedness with undergraduate training • • • • • •

Critical gaps in supervisor interaction Duration and engagement of supervision Quality of supervision Subjectivity of supervision Training of supervisors Support provided for supervisors

• Duration of feedback to interns • Quality of feedback to interns • Benefits of feedback during internship

Major descriptive themes

Analytical themes

Challenges in the learning environment

Preparedness

Impact of the learning environment

Supervisor interaction

Feedback

LMICs = lower-middle-income countries.

non-procedural skills’, ‘use of self-assessment instead of direct observed assessment’ and the ‘influence of the learning environment on internship’.

Discussion

Clear differences were identified in various aspects of WBA between the international and SA settings. The first and most obvious difference was noticeable in the number of studies and research articles reporting on issues relating to WBA during internship. The second difference related to the dearth of studies conducted in the field of medical and health professions education in LMICs and in SA. The limited number of reported research projects in medical education from sub-Saharan African countries has been documented before.[15-17] This review confirms the previous observation and confirms the discrepancy in literature relating to research on WBA among interns. The review of the literature relating to WBA in high-income countries showed a clear focus on assessing the knowledge, skills and attitudes of interns by using a competency-based assessment framework. The two broad areas of competency focused on the assessment of core clinical skills and nonclinical competencies, including communication and professionalism.[18,19] The analysis of the international literature also indicated a shift towards the use of ‘entrustable professional activities (EPAs)’ as a possible framework for measuring activities of trainees in specific workplace settings. The use of these ‘concrete critical activities which infer the presence of multiple competencies help[s] bridge the gap between the theories of competencybased education and clinical practice. These EPAs should be ‘independently executable, observable and measurable’; an example of such an activity is executing a patient handover.[21] The concept of milestones, as introduced in best-evidence international practice, provides greater clarity and understanding of

the incremental development of competencies in junior doctors over time.[20-22] SA studies, however, did not report on the use of competency-based frameworks, EPAs or any other time-based indicators (milestones) to measure progress of interns in the work-based setting.[20] The main focus in the SA literature was the assessment of core procedural skills in acute emergency and clinical situations. SA studies indicated the suboptimal performance of interns in paediatric resuscitation, obstetric practice, anaesthesia, orthopedics, intubation, circumcision and appendectomies.[9,15,23,24] The emphasis on procedural skills in acute emergencies possibly reflects the narrow interpretation of the role SA interns are expected to play within institutional hierarchical systems, and disregard for assessing their competence in knowledge, attitudes and non-clinical functions. This lack of studies on non-procedural skills in SA identifies clear gaps in the assessment methods of interns in SA. Gaps in the assessment of non-procedural skills such as prescribing medication, communication and mental-state examinations were also identified in a systematic review of non-technical skills in LMICs that highlighted the lack of tools to assess non-procedural skills.[16] This gap indicates a need for SA to align intern training and assessment frameworks with undergraduate and postgraduate practice, which frame curricula and assessment practices within frameworks such as CanMEDS.[25] The use and benefits of EPAs specific to each discipline may make the acceptance of their use for assessment, and the measuring of competencies, much easier.[19] The literature from high-income countries reflected a trend away from relying on self-assessment as the sole means of determining intern performance. Self-assessment is shown to have a poor correlation with other modes of evaluation.[26-28] Interns were unable to judge their own performance.[29] The least-skilled intern seems to have the poorest ability to self-assess, which they are often unable to correct even with support.[26]

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Research Aggregated self-assessment was more useful for tracking cohorts and for programme evaluation.[30] SA practice largely emphasises self-reported assessments of interns.[1] Some SA studies have also indicated that poorly skilled interns were unduly optimistic about their own performance,[31] and that interns’ perceptions of competence were unrelated to the assessments by others of their performance.[32] This may strengthen the argument for the use of multiple methods of assessment, instead of the reliance on self-assessment. Innovations in WBA from developed countries feature the use and validation of tools that use direct observation. These tools, used either alone or in combination with other modes of assessment, are often centrally developed for a country or district and require significant human resources and administration. The use of Mini CEX (clinical evaluation exercise), mini PAT (peer assessment tool) and DOPS (directly observed procedural skills) systems was reported in the international literature, reflecting the use of multiple tools of assessment of interns in high-income countries. The 360-degree multisource feedback (MSF) assessment process was found to have robustness and feasibility in the first year of internship.[33] MSF tools were well received and well aligned to the job, and improvements became evident owing to the use of the MSF strategy.[34] The MSF process was regarded as a viable strategy to assess a large number of doctors.[35] SA literature did not feature articles on the use of directly observed tools for WBA, reflecting a major gap in the reporting, validation and use of efficient assessment tools among interns. In SA it is likely that inclusion of all categories of staff, including middle-grade medical, allied health professionals and nursing staff, in assessments could promote integration, teamwork and the assessment of non-core skills such as communication and professionalism that is currently missing from the assessment system. The lack of multiple directly observed tools of assessment for interns in SA reflects the current status of assessment, the challenges and the shortage of sufficiently experienced supervisors.[7,8] Various factors were documented in the literature to indicate the challenges faced by internship training in SA and other LMICs. This context is noted for having high workloads, resource limitations and inadequate supervisor support and training. The consequence of this constrained environment of suboptimal supervision is compromising of patient safety, especially due to poorly skilled and trained interns. International research among interns reflects on the assessment of practices to ensure that patient safety is prioritised.[36] In SA hospitals, there is a lack of emphasis on assessing interns on practices that ensure patient safety, despite identification of the fact that their excessive workload and long work hours compromise patient care.[8,37] Despite the challenges involved, proven innovations and developments in assessment processes from high-income countries need to be adapted and explored within the context of SA and LMICs to optimise the training of interns.

prescribing, mental-state evaluations and documentation, among other ‘soft skills’, need to be given adequate place in the assessment of interns in SA. There is a need to recognise the ‘novice-to-expert’ trajectory among interns over a 2-year period. The use of milestones should be incorporated within this framework, as well as the use of clearly defined disciplinespecific EPAs that can be easily measured to determine competencies. Multiple tools of assessment need to be used that focus on direct observation as well as elements of self-assessment. Intern assessment needs to include tools that focus on patient safety. The MSF tool is practical, usable for large numbers and will enable teamwork. This process will enable an equitable emphasis on skills such as communication and professionalism, which are currently neglected. Further research on the use of directly observed tools of assessment that assess all types of skills and competencies within a resource-challenged context needs to be done.

Recommendations

Acknowledgements. Mrs. Leora Sewnarain for assistance with typesetting and Ms Rani Moodley for assistance with the database searches. Author contributions. KLN was responsible for study design, data collection, data analysis and drafting the manuscript. JVW was responsible for supervision of the entire project, study design and manuscript review. MA was responsible for supervision of the entire project and manuscript review. Funding. MEPI funding: This publication was made possible by grant number

The WBA of interns in South Africa needs to adopt a broad competencybased framework that encompasses the assessment of knowledge, skills and attitudes. Linking internship with the graduate competency-based frameworks of undergraduate and postgraduate courses will assist in this. Both procedural and non-procedural skills need to be assessed. Nonprocedural skills in internship, including skills in communication,

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Strengths and limitations

Despite the differences in the quantity of studies emanating from LMICs as compared with high-income countries, this review attempted to identify significant differences in assessment practice and propose recommendations to improve WBA. This review was restricted to articles published in English over the last 17 years. Literature included reports, guidelines theses, policy reviews and stakeholder analyses. Abstracts presented at conferences relating to the assessment of medical interns were not included for analysis, if they could not be found via an electronic database. Studies of first-year residents in the US context were included whilst studies with defined internship periods elsewhere were focused on.

Conclusions

In SA, the focus in WBA among interns is on assessing core procedural skills without a competency-based framework. This occurs to the detriment of assessing non-procedural skills and non-clinical competencies, and fails to consider milestones in this process. Self-assessment methodologies, which have proved to be inadequate in assessing interns, predominate in SA. The use of multiple methods of assessment for interns, including tools that incorporate direct observation, is being implemented in most highincome countries, and needs to be evaluated for use in SA. The use of MSF is proving efficient for large numbers of doctors. Many developments in WBA within high-income countries are relevant to the SA context, and their adaptation or adoption within a resource-constrained context should be explored to overcome gaps identified in intern training. *The datasets extracted and analysed in this study are available from the corresponding author on reasonable request.

Research R24TW008863 from the Office of the US Global AIDS Co-ordinator and the US Department of Health and Human Services, National Institutes of Health (NIH OAR and NIH ORWH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the US government. Conflicts of interest. None. 1. Medical and Dental Professions Board, Health Professions Council of South Africa. Handbook on Internship Training. Guidelines for Interns, Accredited Facilities and Health Authorities. Pretoria: HPCSA, 2016. 2. Frenk J, Chen L, Bhutta Z, 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 3. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007;29(9-10):855-871. https://doi.org/10.1080/01421590701775453 4. Burch V. Portfolios for assessment and learning: Guide Supplement 45.1 – Viewpoint. Med Teach 2011;33(12):1029-1031. https://doi.org/10.3109/0142159x.2011.596589 5. Bateman C. System burning out our doctors – study. S Afr Med J 2012;102(7):593-594. https://doi.org/10.7196/ samj.6040 6. Ibeziako O, Chabikuli O, Olorunju S. Hospital reform and staff morale in South Africa: A case study of Dr Yusuf Dadoo Hospital. S Afr Fam Pract 2013;55(2):180-185. https://doi.org/10.1080/20786204.2013.10874330 7. Tumbo J, Sein NN. Determinants of effective medical intern training at a training hospital in North West Province, South Africa Afr J Health Professions Ecuc 2012;4(1):10-14. https://doi.org/10.7196/ajhpe.100 8. Bola S, Trollip E, Parkinson F. The state of South African internships: A national survey against HPCSA guidelines. S Afr Med J 2015;105(7):535-539. https://doi.org/10.7196/samjnew.7923 9. Peters F, van Wyk J, van Rooyen M. Intern to independent doctor: Basic surgical skills required for South African practice and interns’ reports on their competence. S Afr Fam Pract 2015;57(4):261-266. https://doi.org/10.1080 /20786190.2014.976954 10. Van Heerden, BB. Effectively addressing the health needs of South Africa’s population: The role of health professions education in the 21st century. S Afr Med J 2012;103(1):21-22. https://doi.org/10.7196/samj.6463 11. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8(1):45. https://doi.org/10.1186/1471-2288-8-45 12. Thomas J, Harden A, Oakley A, et al. Integrating qualitative research with trials in systematic reviews. BMJ 2004;328(7446):1010. https://doi.org/10.1136/bmj.328.7446.1010 13. Mays N, Pope C. Assessing quality in qualitative research. BMJ 2000;320(7226):50. https://doi.org/10.1136/ bmj.320.7226.50 14. Kuper A, Lingard L, Levinson W. Critically appraising qualitative research. BMJ 2008:337(3):a1035-a1035. https://doi.org/10.1136/bmj.a1035 15. Burch V, Van Heerden B. Are community service doctors equipped to address priority health needs in South Africa? S Afr Med J 2013;103(12):905. https://doi.org/10.7196/samj.7198 16. Scott J, Revera Morales D, McRitchie A, et al. Non-technical skills and healthcare provision in low- and middleincome countries: A systematic review. Med Educ 2016;50(4):441-455. https://doi.org/10.1111/medu.12939 17. Tutarel O. Geographical distribution of publications in the field of medical education. BMC Med Educ 2002;2(1):1-7. https://doi.org/10.1186/1472-6920-2-3 18. Carr S, Celenza A, Lake F. Assessment of junior doctor performance: A validation study. BMC Med Educ 2013;13(1):1-6. https://doi.org/10.1186/1472-6920-13-129

19. Archer J, Norcini J, Southgate L, Heard S, Davies H. Mini-PAT (Peer Assessment Tool): A valid component of a national assessment programme in the UK? Adv Health Sci Educ 2006;13(2):181-192. https://doi.org/10.1007/ s10459-006-9033-3 20. Hicks PJ, Schumacher DJ, Benson BJ, et al. The pediatrics milestones: Conceptual framework, guiding principles, and approach to development. J Grad Med Educ 2010;2(3):410-418. https://doi.org/10.4300/jgme-d-10-00126.1 21. Ten Cate O, Scheele F. Viewpoint: Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med 2007;82(6):542-547. https://doi.org/10.1097/acm.0b013e31805559c7 22. Gardner A, Scott D, Choti M, Mansour J. Developing a comprehensive resident education evaluation system in the era of milestone assessment. J Surg Educ 2015;72(4):618-624. https://doi.org/10.1016/j.jsurg.2014.12.007 23. Ash S. A comparison of two months versus two weeks of internship anaesthesia training. S Afr J Anaesth Analg 2009;15(1):23. https://doi.org/10.1080/22201173.2009.10872583 24. Nkabinde T, Ross A, Reid S, Nkwanyana N. Internship training adequately prepares South African medical graduates for community service – with exceptions. S Afr Med J 2013;103(12):930-934. https://doi.org/10.7196/ samj.6702 25. Binnendyk J, Watling C. CanMEDS in context: A transition to residency innovation. Med Educ 2015;49(11):11501151. https://doi.org/10.1111/medu.12862 26. Davis D, Mazmanian P, Fordis M, et al. Accuracy of physician self-assessment compared with observed measures of competence. JAMA 2006;296(9):1094. https://doi.org/10.1001/jama.296.9.1094 27. McKenzie S, Burgess A, Chapman R, Mellis C. Pre-interns: Ready to perform? Clin Teach 2015;12(2):109-114. https://doi.org/10.1111/tct.12254 28. Barnsley L, Lyon P, Ralston S, et al. Clinical skills in junior medical officers: A comparison of self-reported confidence and observed competence. Med Educ 2004;38(4):358-367. https://doi.org/10.1046/j.13652923.2004.01773.x 29. Ibrahim J, MacPhail A, Chadwick L, Jeffcott S. Interns’ perceptions of performance feedback. Med Educ 2014;48(4):417-429. https://doi.org/10.1046/j.1365-2923.2004.01773.x 30. D’Eon M, Trinder K. Evidence for the validity of grouped self-assessments in measuring the outcomes of educational programs. Eval Health Prof 2013; 37(4):457-469. https://doi.org/10.1177/0163278713475868 31. Burch V, Nash R, Zabow T, et al. A structured assessment of newly qualified medical graduates. Med Educ 2005;39(7):723-731. https://doi.org/10.1111/j.1365-2929.2005.02192.x 32. Kusel B, Farina Z, Aldous C. Anaesthesia training for interns at a metropolitan training complex: Does it make the grade? S Afr Fam Pract 2014;56(3):201-205. https://doi.org/10.1080/20786204.2014.936664 33. Hesketh E, Anderson F, Bagnall G, et al. Using a 360° diagnostic screening tool to provide an evidence trail of junior doctor performance throughout their first postgraduate year. Med Teach 2005;27(3):219-233. https://doi. org/10.1080/01421590500098776 34. Miller A, Archer J. Impact of workplace based assessment on doctors’ education and performance: A systematic review. BMJ 2010;341:(1-6). https://doi.org/10.1136/bmj.c5064 35. Wilkinson J, Crossley J, Wragg A, et al. Implementing workplace-based assessment across the medical specialties in the United Kingdom. Med Educ 2008;42(4):364-373. https://doi.org/10.1111/j.1365-2923.2008.03010.x 36. Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Saint S. Systematic review: Effects of resident work hours on patient safety. Ann Intern Med 2004;141(11):851-857. https://doi.org/10.7326/00034819-141-11-200412070-00009 37. Erasmus N. Slaves of the state – medical internship and community service in South Africa. S Afr Med J 2012;102(8):655-658. https://doi.org/10.7196/samj.5987

Accepted 15 August 2017.

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Research

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

‘Sense of belonging’: The influence of individual factors in the learning environment of South African interns K L Naidoo,1,2 MB ChB, DCH, FCPaed; J van Wyk,3 BSc Ed, BEd, MEd, PhD; M Adhikari,2 MB ChB, FCPaed, PhD 1

King Edward VIII Hospital, KwaZulu-Natal Department of Health, Durban, South Africa

Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Department of Clinical and Professional Practice, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: K Naidoo (naidook9@ukzn.ac.za)

Background. The focus is usually on organisational issues when reporting factors influencing the perceptions of South African (SA) medical interns regarding their learning environment (LE). Individual demographic factors are now being recognised as equally important in influencing these perceptions. Objective. To determine whether individual demographic factors influence interns’ perceptions of the LE during their paediatrics rotation in hospitals burdened with high disease in SA. Methods. Perceptions of the LE among interns in KwaZulu-Natal, SA, were assessed in December 2015, using a validated version of the Postgraduate Hospital Educational Environmental Measure (PHEEM). Overall and subscale PHEEM scores were calculated using Likert scales. The association of these scores with various sociocultural factors relevant to the SA context, previous educational exposure and year of internship were examined using ANOVA or Student t-tests. Results. A total of 209 interns (59.3%) was sampled. The ethnic breakdown of sampled interns reflected the changing demographic profile of SA junior doctors. Statistically significant associations of overall and teaching subscale PHEEM scores were found with ethnicity (p=0.024), urban/rural status (p=0.023), year of internship (p=0.0047) and university origin (p=0.015). These factors corroborated characteristics that reflect both past disadvantage in the SA context, and those of being an ‘outsider’ in an established group. Conclusions. Intern training programmes in SA need to recognise that individual demographic factors influence interns’ perceptions in the context of teaching and mentoring in a discipline. With rapid changes in the demographic profiles of junior doctors, SA intern trainers need to enable a ‘sense of belonging’ in LEs. Afr J Health Professions Educ 2018;10(1):50-55. DOI:10.7196/AJHPE.2018.v10i1.953

The learning environment (LE) refers to a ‘set of factors’ that describes the experiences of the trainee within an organisation.[1] These factors can be divided into three components. The first is the ‘physical environment’ (facilities, comfort, safety and food), which are the organisational aspects. Work load and work hours would also relate to this aspect.[2] The second component is the ‘intellectual environment’, which includes support provided for scholarly activities during training, learning with patients and using evidence-based knowledge and skills.[2] The third component is the ‘emotional environment’, referring to the social support provided, the levels of harassment experienced by the trainee and the trainee’s characteristics that may facilitate or hinder access to support, including that offered by a supervisor.[2] The effect of the LE appears to be mediated by the trainees’ own perceptions thereof, and this has been shown to be an important determinant of attitude, satisfaction and achievements.[3,4] An optimally functioning clinical LE, where medical interns perceive it as such, is important for successful training in any platform to develop competent physicians.[5] Emphasis has previously been placed on evaluating the organisational aspects of these training platforms.[6,7] The environment in which South African (SA) medical interns train has been associated with excessive workloads, long hours, high stress levels, burnout and reports of suboptimal

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supervision.[8-10] While these organisational aspects form a significant segment of the factors affecting perceptions of the LE, the influence of individual demographic factors also needs to be explored and understood.[11] The legacy of apartheid policies and persistent social inequity in SA has continued to manifest in society, including in education.[12] The characteristics linked to social inequity, such as gender, ethnicity and socioeconomic status, have persisted, and remain useful as criteria to measure previous disadvantage. Urban/rural status still reflects racial and socioeconomic divisions, and plays an important role in access to and success in higher education.[12] Previous educational experiences are considered important contextual factors in learning and in the SA context; huge disparities exist between the education offered by fee-paying compared with non-fee-paying schools.[13] In the higher-education climate, including health professions education in SA, calls are being made to challenge and dismantle the colonial curricula mindsets that perpetuate the ideological framework that allows one culture to dominate others.[14] While these calls for ‘decolonisation’ include aspirations for the ‘creation of a humanising culture of practice that is not at odds with lived practice’, education processes are still noted to have a ‘mandated ignorance’, with LEs seemingly blind to issues of race and difference.[15]

Research Demographic factors are being recognised as important indicators of inequity that can be used for its redress, and most SA medical schools have amended their undergraduate selection criteria towards transformation norms.[13] This has seen a rapid change in the demographic composition of the intern population in SA. As a result of these changes, interns of differing socioeconomic and educational backgrounds are allocated to work and learn together in regional hospitals throughout the country for a 2-year internship. The internship programme includes all major medical specialties, including paediatrics.[16] It is not clear how the changes in the composition of the group of newly qualified doctors have influenced their perceptions of the LE, especially in paediatrics. An improved understanding of these changes would facilitate the improvement of training for junior doctors. The Postgraduate Hospital Educational Environmental Measure (PHEEM) is a well-recognised instrument used internationally to assess the LE in postgraduate medicine.[17-19] A local SA version of the PHEEM instrument was validated among a cohort of paediatric interns in four hospital complexes in Durban and Pietermaritzburg, KwaZulu-Natal (KZN).[18] While organisational and institutional factors were identified as obstacles to creating an ideal LE, significant differences were noted in the way interns and their supervisors perceived the LE, especially with regard to supervision and mentoring.[18] In this study, we report on the influence of individual demographic factors on perceptions of the LE among this cohort. This study was thus conducted to: (i) determine whether individual demographic factors influence interns’ perceptions of their experiences in the LE in paediatrics; (ii) compare the perceptions of first- and second-year interns of the LE in the paediatric rotation; and (iii) determine the influence of previous educational experiences on paediatric interns’ perceptions of their LE.

Methods

Research design and ethics approval

This was an observational, cross-sectional cohort study. Ethical approval for the study was obtained from the University of KZN Biomedical Research Ethics Committee (ref. no. BE 177/15), and gatekeepers’ permission was granted from the various institutions, as well as the Health Research and Knowledge Management subcomponent of the Department of Health in the province of KZN. The study population consisted of all eligible interns, who were informed of the study and invited to participate. Participants were informed of their rights, and could withdraw at any stage. Participation in the study was voluntary, and the anonymity and confidentiality of respondents were assured. The surveys were group-administered at preexisting intern meetings, and the primary researcher was blinded to the individual responses as no identifying details were required.

The instrument

The PHEEM has been used to assess the LE among interns throughout the world.[17] The PHEEM used in our study had eight minor changes made to the original 40 items to accommodate terminology relevant to the SA and paediatric setting.[18] Each item was scored by participants on a fivepoint Likert scale, where 1 indicated ‘strongly disagree’ and 5 represented a ‘strongly agree’ response. The original questionnaire used a 0 - 4 scale, while we followed a more conventional scale of 1 - 5, as used by some authors in clinical settings.[3]

Procedure

The sample population included all interns who had completed a paediatrics rotation at four hospital complexes (comprising eight hospitals) in both major cities of the KZN province in December 2015. Demographic data, including gender, ethnicity, home language, urban/rural status and the highest educational level of a ‘parental figure’ were obtained. Three categories of urban/rural status were recognised, namely urban (mainly city and suburban neighbourhoods), semi-urban (reflecting mainly ‘township’ neighbourhoods) and rural (mainly outside of an urban or semi-urban area). These distinctly different area types reflect significant racial and socioeconomic divisions in the SA context.[12] Data on prior educational exposure were also solicited, on the type of high school attended (whether fee-paying or non-fee-paying) and university origin (whether the intern graduated from the local university (University of KwaZulu-Natal) or from another university in a different province or country), and on interns’ finalyear undergraduate paediatric performance.

Sample size

A sample-size calculation was based on the comparison of the PHEEM scores between the intern group and various demographic variables. Using a one-way ANOVA with up to four groups, the sample size of 209 interns was found to be adequate, as a sample of 180 was required to achieve 80% power at a 5% significance level.[20]

Data analysis

The overall PHEEM scale and subscale scores were calculated for each participant. Where there were missing data, means were computed based on data for available items, provided this did not exceed 20% of the items. The overall score was computed as the average of all 40 items. The negatively worded items 7, 8, 11 and 13 were reverse-scored. For the descriptive analysis, categorical variables were summarised by frequency and percentage tabulation. Continuous variables were summarised by mean, standard deviation, median and interquartile range. The association between the various demographic variables, year of internship and the factors associated with previous educational experiences, with overall PHEEM score as well as the three subscale PHEEM scores, was determined by the t-test or ANOVA (for more than two categories). The strength of the association was measured by Cohen’s d. The following scale of interpretation was used: ≥0.8 = large effect; 0.5 - 0.79 = moderate effect; and 0.2 - 0.49 = small effect. Data analysis was carried out using SAS Version 9.4 for Windows (SAS, USA). The 5% significance level was used throughout.

Results

A response rate of 59.3% was achieved, as 209 completed questionnaires were returned from a potential pool of 352 interns. Of these, 35.8% of the interns assessed were in their first year and 63.8% in their second year of internship, and 55% were female. The mean age of the whole group was 26.2 years (standard deviation (SD) 2.6; range 20 - 37 years). A number of factors were examined to investigate the influence of previous disadvantage on perceptions. Table 1 presents the sociocultural characteristics of the sampled interns. Table 2 shows the composition of sampled interns with regard to variables indicating previous educational experiences. An examination of the influence of various demographic factors on the overall PHEEM scores indicated a number of significant findings. Table 3 depicts the

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Research Table 1. Sociocultural characteristics of sampled interns (N=209) Variable Gender Male Female Ethnicity White Indian Black African Coloured Home province KZN Gauteng Western Cape Eastern Cape Urban/rural status Urban Semi-urban (township) Rural Home language* English Afrikaans Zulu Xhosa Highest achieved educational level of parent/caregiver Less than high school completion Completed high school Non-university tertiary University

n (%) 91 (45.05) 111 (54.95) 53 (27.89) 64 (33.68) 60 (31.58) 13 (6.84) 112 (66.67) 27 (16.07) 23 (13.69) 6 (3.57) 119 (58.91) 63 (31.19) 20 (9.90) 105 (62.87) 29 (17.37) 25 (14.97) 8 (4.79) 15 (7.54) 17 (8.54) 33 (16.58) 134 (67.34)

KZN = KwaZulu-Natal. *Other home languages were insignificantly represented, so excluded from the table/analysis.

Table 2. Previous educational experience of sampled interns (N=209) Variable High school type Non-fee-paying government Fee-paying government Fee-paying private University origin: local (UKZN) v. non-local (all other) Local Non-local University origin: SA v. non-SA SA Non-SA Undergraduate paediatrics performance <60% pass 60% - 70% pass >70% pass

n (%) 87 (43.50) 63 (31.50) 50 (25.00) 60 (29.56) 143 (70.44) 162 (81.00) 38 (19.00) 19 (9.45) 112 (55.72) 70 (34.83)

UKZN = University of KwaZulu-Natal.

relationship between all the individual demographic variables, including sociocultural factors, factors indicating previous educational experience and internship year, and the overall PHEEM score.

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Table 3. Comparisons of the overall mean PHEEM scores with all demographic variables Sociocultural factors

n, mean (SD)

p-value*

Gender Male 90, 3.48 (0.48) Female 109, 3.52 (0.52) Ethnicity White 53, 3.57 (0.36) Indian 64, 3.55 (0.55) Black African 57, 3.37 (0.55) Coloured 13, 3.78 (0.27) Home province KZN 11, 3.52 (0.54) Gauteng 26, 3.64 (0.26) Western Cape 23, 3.50 (0.38) Eastern Cape 6, 3.46 (0.34) Urban/rural status Urban 117, 3.59 (0.45) Semi-urban (township) 62, 3.37 (0.60) Rural 20, 3.50 (0.44) Home languageâ&#x20AC; English 105, 3.55 (0.48) Afrikaans 29, 3.64 (0.35) Zulu 24, 3.40 (0.59) Xhosa 8, 3.29 (0.48) Highest level of education of parent/caregiver Less than high school completion 15, 3.43 (0.81) Completed high school 17, 3.40 (0.50) Non-university tertiary 32, 3.51 (0.50) University 133 3.54 (0.48) Internship year First year 72, 3.37 (0.56) Second year 126, 3.58 (0.47) High school attended Non-fee-paying government 85, 3.49 (0.55) Fee-paying government 62, 3.49 (0.51) Fee-paying private 50, 3.57 (0.48) University origin: local (UKZN) v. non-local Local (UKZN) 59, 3.64 (0.56) Non-local 141, 3.45 (0.49) University origin: SA v. non-SA SA 160, 3.54 (0.50) Non-SA 37, 3.38 (0.53) Undergraduate paediatric pass mark >70% 69, 3.51 (0.45) 60% - 70% 110, 3.50 (0.55) <60% 19, 3.50 (0.54)

0.59

0.024

0.68

0.023

0.16

0.66

0.0047

0.61

0.094

0.99

PHEEM = Postgraduate Hospital Educational Environmental Measure; UKZN = University of KwaZulu-Natal. *Statistical significance was indicated at p<0.05. â&#x20AC; Other home languages were insignificantly represented, so excluded from the table/analysis.

Sociocultural variables

There was a significant association between ethnicity and the overall PHEEM score. Interns who had self-identified as black African had lower

Research mean PHEEM scores than their white, Indian or coloured colleagues. This finding was reiterated when comparing ethnicity with PHEEM scores on the teaching subscale (p=0.0026) (Table 4). The effect size was large when comparing the scores of coloured (d=0.88) and Indian (d=0.5) with black African interns.

There was a significant association between the mean PHEEM score and urban/rural status, with those who indicated that they came from a semiurban (mainly referring to a ‘township’ area) environment having a lower overall PHEEM score than those from urban (city or suburbs) rural areas

Table 4. Comparison of PHEEM teaching subscale scores with all demographic variables Sociocultural factors Gender Male Female Ethnicity White Indian Black African Coloured Home province KZN Gauteng Western Cape Eastern Cape Urban/rural status Urban Semi-urban (township) Rural Home language English Afrikaans Zulu Xhosa Highest level of education of parental figure Less than high school completion Completed high school Non-university tertiary University Year paediatrics rotation done First year Second year High school attended Non-fee-paying government Fee-paying government Fee-paying private University origin: Local (UKZN) v. non-local Local (UKZN) Non-local University origin: SA v. non-SA university qualified* SA Non-SA Undergraduate paediatric pass mark >70% 60% - 70% <60%

mean

p-value

90 110

3.56 3.57

0.55 0.62

0.91

53 64 58 13

3.62 3.68 3.36 3.89

0.38 0.65 0.66 0.30

0.0026

110 27 23 6

3.60 3.67 3.55 3.47

0.64 0.29 0.42 0.51

0.81

117 63 20

3.65 3.42 3.52

0.53 0.68 0.52

0.032*

105 29 24 8

3.65 3.69 3.38 3.22

0.57 0.33 0.70 0.61

0.032

15 17 33 133

3.35 3.42 3.58 3.61

0.94 0.53 0.58 0.57

0.32

72 127

3.41 3.64

0.64 0.56

0.0083†

3.54

0.66

62 50

3.51 3.68

0.57 0.54

59 142

3.74 3.49

0.67 0.56

0.0068

161 37

3.59 3.45

0.59 0.60

0.19‡

70 110 19

3.56 3.56 3.56

0.55 0.63 0.67

0.30

>0.99

*On role autonomy subscale p=0.013. † On role autonomy subscale p=0.00089. ‡ On social subscale p=0.047.

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Research (Table 3). There were statistically significant associations between urban/ rural status and the mean PHEEM score on the teaching subscale (p=0.032) and the PHEEM score on the role-autonomy subscale (p=0.013) (Table 4). Table 4 shows the mean PHEEM teaching subscale scores compared with the major languages spoken by interns, which also showed a significant association (p=0.032). We found no statistically significant relationship with gender, home province or the highest educational level of an intern’s parental figure, when comparing overall PHEEM scores and all subscale scores with these sociocultural variables. There were no significant associations when we compared the PHEEM subscale scores on the social-support scales with all sociocultural variables.

Internship year

The mean PHEEM score for interns in their first year was significantly lower than that of interns in their second year of internship. This significant difference between year 1 and 2 interns was seen when comparing PHEEM scores on the teaching subscale (p=0.0083) (Table 4), as well as on the PHEEM role-autonomy subscale scores (p=0.0089).

Prior educational exposure

Table 4 indicates that interns who had graduated from the local university had significantly higher perceptions of the LE than interns who had graduated outside the province. There was a significant association between the mean PHEEM scores of interns who studied overseas, and SA-trained interns, on the social support subscale score. Neither the type of high school attended nor undergraduate performance in paediatrics showed any statistically significant relationship with overall PHEEM score or with the PHEEM scores on the teaching, role-autonomy and social support subscales.

Discussion

In this study, individual demographic factors are shown to have a major impact in influencing interns’ perceptions of the LE. These characteristics have been largely neglected as factors to consider in influencing internship, while organisational factors such as work-hours and the state of the physical infrastructure of the LE have been focused on. The good response rate in our sample was in keeping with surveys using the PHEEM instrument elsewhere,[17] and the distribution of sampled interns closely represented the allocation of interns across the hospital complexes. The 2015 cohort shows an increasing representation of female and black African newly qualified doctors compared with previous years, and is beginning to reflect the implementation of amended selection criteria at SA medical schools.[13] However, evaluating the demographic characteristics of the sampled interns revealed that the newly qualified doctors are still largely drawn from middle-class backgrounds, with nearly 60% of interns originating from urban areas, 56.5% attending fee-paying schools and over 60% from homes with at least one parental figure having obtained a university qualification. In this study, ethnicity, language and urban/rural status were identified as factors that are significantly associated with lower perceptions of the LE in internship. These relationships corroborate the notion that interns from previously disadvantaged communities have poorer perceptions of the LE than most of their peers in internship. Gender was not identified as a factor influencing perceptions of the LE. Paediatrics is generally a discipline with a larger female composition, and thus probably reflects a more gender-

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sensitive environnment. Various other studies have shown the influence of gender on the overall PHEEM scores, especially in disciplines with an underrepresentation of female doctors such as general surgery and intensive care.[21,22] This study showed a clear difference in the perceptions of interns who were in their first year as compared with those in the second year of internship. Various studies internationally corroborate this finding, with juniors having less positive perceptions of the LE than senior trainees.[23] Interns who did not graduate from the university supporting the internship training platform, and those who graduated outside SA, also displayed poorer perceptions of the LE. These findings are consistent with the findings of studies that reported higher levels of stress among interns at hospitals in SA who graduated from non-local universities.[9] The findings show that while indices of socioeconomic disadvantage, especially ethnicity and urban/rural status, did influence interns’ perceptions of the LE, these were not the only factors. The combination of factors that significantly influenced the perceptions of the LE relate to characteristics of being ‘new’ or ‘different’ to the established norms or ‘culture’. The factors can furthermore be categorised as individual characteristics that seemingly add to perceptions of marginalisation or ‘alienation’ in interns who experienced their training as ‘being isolated from a group activity in which they should be involved’.[24] This difficulty in developing a ‘sense of belonging’ is of concern, especially as learning within the clinical environment relies heavily on participation within a ‘community of practice’ that is provided by the authentic work environment. Learning in internship occurs within the context of ‘legitimate, peripheral participation’ within a social context, and is an increasingly communal and negotiated contract.[25,26] This learning, while understood at an individual level, occurs at group level, and involves the acquisition of knowledge, skills, attributes, values and competencies and ‘participation in social processes’ where learning is inextricably linked to and embedded in its context.[27] The interaction between supervisors and interns occurs within a historic context, and reflects a ‘colonised’ culture where the relationship of dominance creates the concept of the ‘outsider’,[28] and in new incumbents, a notion of being the ‘other’ or not being welcome in an already established setting that does not recognise his/her presence. These unequal power relations and marginalisation may contribute to a failure to ensure that all interns are brought into full participation.[14] The learning climate, in this context, may thus be difficult for interns who experience it from the position of ‘outsiders’ or ‘others’, and they are unlikely to seek or initiate a search for effective mentorship, a situation that further compromises the supervision opportunity. These findings, which are of relevance to all health professionals and to undergraduate universities, indicate the need for efforts to ensure that all interns develop a ‘sense of belonging’ in their training platform. The impact of the findings on policy includes the recognition by intern accreditation bodies of the role of individual intern characteristics as important factors to consider when developing intern training curricula and oversight frameworks. This can translate into processes to mandate the development of welcoming environments that facilitate the integration of interns from the start, so that they commence as a team respecting and appreciating each other’s contexts and diversity. The calls to work as a collective to ‘decolonise’ and humanise training have resonance here.[14] Intern programmes and curricula need to change to evaluate intern and supervisor interactions, to ensure that all interns experience optimal supervision and that individual demographic factors are taken into consideration.

Research As the SA medical community transforms to reflect the true demographics of the country, efforts should be made to ensure the inclusion of and support for ‘engagement’ of junior doctors within hierarchical and ‘established’ communities of practice. Individual demographic factors in the LE can no longer be regarded as minor factors in the learning process, and more work is needed to understand how they impact on successful orientation and learning, especially in the formative period of internship.

Limitations

The sample only included interns linked to hospitals in one province, and the possibility exists that the findings could reflect a regional bias. However, the large number of interns sampled, the good response rate and the choice of large hospitals with known high disease burdens is thought to be adequately representative of the SA internship programme, and adds confidence that the findings would probably represent those of others, including other health professionals, in the SA setting. The PHEEM instrument was originally created for postgraduate registrars; however, we believe that the LE of interns’ work resembles that of the postgraduate registrar trainees, and PHEEM is therefore highly relevant. This study did not explore the training received or the previous clinical experience of supervisors, which would influence the mentorship relationship in this setting. This study used quantitative methods to assess the LE and to fully understand the LE in depth; a qualitative evaluation of interns’ perceptions of the LE is also needed.

Conclusion

While organisational factors have been noted to affect the LE of interns in SA, our research indicates that individual demographic factors are important. Perceptions of the LE, as measured by validated and reliable tools like the PHEEM, are influenced by various demographic and individual factors. First-year interns who have not graduated from the local university and who are from previously disadvantaged socioeconomic groups in SA are more likely to perceive a poorer LE than their peers. These factors affecting a ‘sense of belonging’ will become apparent in challenged situations where there is inadequate supervision and mentoring, and within the rapidly transforming demographic environment in SA as it attempts to ‘decolonise’ its practices. Efforts must be made to ensure that medical-intern and all healthprofessional training policies and practices recognise that these factors must be considered during teaching, mentoring and supervision. Further qualitative studies into these relationships are needed to improve our understanding in clinical settings as we aim to train competent health professionals for effective practice in transformed settings. Acknowledgements. The authors would like to express their gratitude to the interns and intern supervisors in the KZN hospitals who participated in this study, Dr Petra Gaylard (DMSA) for assistance with the statistical analyses and Mrs Leora Sewnarain for assistance with typesetting and formatting.

Author contributions. KLN was responsible for study design, data collection, data analysis and drafting the manuscript. JVW was responsible for supervision of the entire work, study design and manuscript review. MA was responsible for supervision of the entire work and manuscript review. Funding. MEPI Funding: This publication was made possible by grant number R24TW008863 from the Office of the US Global AIDS Co-ordinator and the US Department of Health and Human Services, National Institutes of Health (Office of AIDS Research and Office of Research on Women’s Health). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the US government. Conflicts of interest. None.

1. Wall D, Clapham M, Riquelme A, et al. Is PHEEM a multi-dimensional instrument? An international perspective. Med Teach 2009;31:e521-e527. https://doi.org10.1186/1472-6920-14-226 2. Mohanna K, Cottrell E, Wall D, Chambers R. Teaching Made Easy: A Manual for Health Professionals. 1st ed. Boca Raton: CRC Press, 2010. 3. Boor K, Scheele F, van der Vleuten C, et al. Psychometric properties of an instrument to measure the clinical learning environment. Med Educ 2007;41(1):92-99. https://doi.org/10.1111/j.1365-2929.2006.02651.x 4. Genn, J. AMEE Medical education guide no. 23 (Part 1): Curriculum, environment, climate, quality and change in medical ducation - a unifying perspective. Med Teach 2001;23(4):337-344. https://doi. org/10.1080/01421590120063330 5. Hoff T, Pohl H, Bartfield J. Creating a learning environment to produce competent residents: The roles of culture and context. Acad Med 2004;79(6):532-540. https://doi.org/10.1097/00001888-200406000-00007 6. Sein N, Tumbo J. Determinants of effective medical intern training at a training hospital in North West Province, South Africa. Afr J Health Professions Educ 2012;4(1):10-14. 7. Hospital reform and staff morale in South Africa: A case study of Dr Yusuf Dadoo Hospital. S Afr Fam Pract 2013;55(2):180-185. https://doi.org/10.1080/20786204.2013.10874330 8. Erasmus N. Slaves of the state – medical internship and community service in South Africa. S Afr Med J 2012;102(8):655-658. https://doi.org/10.7196/samj.5987 9. Sun GR, Saloojee H, Jansen van Rensburg M, Manning D. Stress during internship at three Johannesburg hospitals. S Afr Med J 2008;98(1):33-35. 10. Bateman C. System burning out our doctors – study. S Afr Med J 2012;102(7):593-594. 11. Tyssen R, Vaglum P, Grønvold N, Ekeberg Ø. The relative importance of individual and organisational factors for the prevention of job stress during internship: A nationwide and prospective study. Med Teach 2005;27(8):726-731. https://doi.org/10.1080/01421590500314561 12. Statistics South Africa. Census 2011 Statistical release. Pretoria: StatsSA, 2012. http://www.statssa.gov.za/ publications/P03014/P030142011.pdf (accessed 23 January 2017). 13. Van der Merwe L, Van Zyl G, St Clair Gibson A, et al. South African medical schools: Current state of selection criteria and medical students’ demographic profile. S Afr Med J 2016;106(1):76-81. https://doi.org/10.7196%2FSAMJ.2016. v106i1.9913 14. Pillay M, Kathard H. Decolonising health professionals’ education: Audiology and speech therapy in South Africa. Afr J Rhetoric 2015;7(1):193-227. 15. Brydon D, Dvořák M. Crosstalk: Canadian and Global Imaginaries in Dialogue. Waterloo: Wilfrid Laurier University Press, 2012. 16. Medical and Dental Professions Board, Health Professions Council of South Africa. Handbook on Internship Training: Guidelines for Interns, Accredited Facilities and Health Authorities. Pretoria: HPCSA, 2016. 17. Soemantri D, Herrera C, Riquelme A. Measuring the educational environment in health professions studies: A systematic review. Med Teach 2010; 32(12):947-952. https://doi.org/10.3109/01421591003686229 18. Naidoo KL, van Wyk JM, Adhikari M. The learning environment of paediatric interns in South Africa. BMC Med Educ 2017;17(1): 235. https://doi.org/10.1186/s12909-017-1080-3 19. Roff S, McAleer S, Skinner A. Development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the UK. Med Teach 2005;27(4):326-331. https://doi.org/10.1080/01421590500150874 20. Faul F, Erdfelder E, Lang A, Buchner A. G*Power 3: A flexible statistical power analysis programme for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39(2):175-191. https://doi.org/10.3758/bf03193146 21. Kanashiro J, McAleer S, Roff S. Assessing the educational environment in the operating room – a measure of resident perception at one Canadian institution. Surgery 2006;139(2):150-158. https://doi.org/10.1016/j.surg.2005.07.005 22. Clapham M, Wall D, Batchelor A. Educational environment in intensive care medicine – use of Postgraduate Hospital Educational Environment Measure (PHEEM). Med Teach 2007;29(6):e184-e191. https://doi. org/10.1080/01421590701288580 23. Pinnock R, Reed P, Wright M. The learning environment of paediatric trainees in New Zealand. J Paediatr Child Health 2009;45(9):529-534. https://doi.org/10.1111/j.1440-1754.2009.01553.x 24. Mann S. Alternative perspectives on the student experience: Alienation and engagement. Stud High Educ 2001;26(1):7-19. https://doi.org/10.1080/03075070020030689 25. Lave J, Wenger E. Legitimate peripheral participation in communities of practice. In: Cross RL, Israelit SB, eds. Strategic Learning in a Knowledge Economy. Boston: Butterworth-Heinemann, 2000:167-182. 26. Mann K. Theoretical perspectives in medical education: Past experience and future possibilities. Med Educ 2010;45(1):60-68. https://doi.org/10.1111/j.1365-2923.2010.03757.x 27. Yardley S, Teunissen P, Dornan T. Experiential learning: AMEE Guide No. 63. Med Teach 2012;34(2):e102-e115. https://doi.org/10.3109/0142159X.2012.650741 28. Spivak GC. A Critique of Postcolonial Reason. Harvard: Harvard University Press, 1999.

Accepted 16 August 2017.

March 2018, Vol. 10, No. 1 AJHPE

Research

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

The effect of undergraduate students on district health services delivery in the Western Cape Province, South Africa S Reid,1 MB ChB, MFamMed, PhD; H Conradie,2 MB ChB, MFamMed; D Daniels-Felix,2 MA (Psych) 1

Primary Health Care Directorate, Faculty of Health Sciences, University of Cape Town, South Africa

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

Corresponding author: S Reid (steve.reid@uct.ac.za)

Background. The quality of care, attitudes of staff and long-term recruitment of practitioners have been shown internationally to improve health services as a result of a health facility accepting students for teaching. This study aimed to develop further insight regarding the impact of undergraduate student involvement on district health services in South Africa to understand the issues in a resource-constrained environment. Objectives. To describe the effect of the placement of undergraduate students on service delivery, and to understand the health service and academic factors that influence this effect. Methods. A descriptive study, using qualitative methods, was undertaken in two rural sites where undergraduate health science students had been recently introduced. Potential respondents were identified to be interviewed on the basis of their positions in the health services, their degree of involvement with students and their knowledge of the health system. Results. Sixteen participants were interviewed, and described the effect of undergraduate students on service delivery in terms of a balance between the burden and benefit. Three pivotal issues, which could tip the balance in favour of one or the other, included the length of time of student rotations, seniority of the students and number of students allocated to a particular site. Overall, it would appear that the balance was marginally in favour of the benefit of student service delivery. Conclusion. Undergraduate students can add value to service delivery under certain conditions, but further research is needed to quantify this effect. Afr J Health Professions Educ 2018;10(1):56-60. DOI:10.7196/AJHPE.2018.v10i1.959

A concern of health managers who are focused on service delivery outputs is the effect of the time taken and resources used by teaching undergraduate students on service delivery. The perception exists that the deliberate teaching of students takes time away from immediate patient care, prolongs ward rounds, slows down outpatient queues and uses more medical supplies. Nonetheless, students doing clinical clerkships can potentially add a pair of educated and willing hands as they learn practically by doing rather than being exclusively taught.[1] The balance between what successive groups of students bring to patient care and what they demand from it, is an ongoing tension that must be actively managed across a clinical teaching platform. International best practice and evidence show that over the long term, the health service benefits of hosting students in practices and hospitals outweigh the demands that they place on the system.[2,3] The quality of care, attitudes of staff, and long-term recruitment of practitioners have all been shown to improve health services as a result of a health facility becoming a teaching site in a developed country.[4] However, apart from one Ugandan study regarding community-based education,[5] not much data exist with regard to the effect of students at district level in low- and middle-income countries, where the service pressures are more intense as a result of severely limited resources to deal with an overwhelming burden of disease. A number of significant developments in health professions education have been initiated in South Africa (SA) over the past decade, in particular the decentralisation of clinical teaching to rural sites[6] and the first yearlong longitudinal placements of medical students in rural district hospitals.[7] District hospitals in SA operate as the second line of medical care in the

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district health system, with the first level being delivered by clinical nurse practitioners in primary care facilities. Our study aimed to develop local evidence of the effect of undergraduate student involvement on the processes and outputs of district health services. What factors tip the balance in favour of service delivery, and what factors benefit the students more? Is one of these factors necessarily at the expense of the other, or can they be mutually beneficial? What factors could contribute to this ideal situation? The answers to these questions have important implications for the way that undergraduate student learning on a public health service platform in resource-constrained settings is conceptualised and planned. These research questions are of equal concern to health service managers as to those in health sciences education; it is therefore difficult to find a single conceptual framework for this study. The starting point for the study could be seen from an educational perspective with implications for curriculum design, in which the theory of service-learning articulated by Dewey[8] and later by Kolb[9] lays equal emphasis on both the service rendered and the experiential learning of the students, with the intention of benefiting equally the provider and the recipient of the services. However, a perspective from management sciences may be more appropriate, in which human resources for health, including students, are one of the many issues that need to be planned, costed, implemented and monitored to keep health services functioning. Borrowing from economics, cost-benefit analysis requires quantitative data that can be costed, but we first need to establish the major issues that have to be compared. This study therefore aimed to

Research identify the key issues in assessing the net effect of students on service delivery at district level.

Methods

A descriptive study was undertaken using qualitative methods to document the process of implementation of undergraduate health science student involvement in three rural sub-districts in the Western Cape Province, SA, and the outcomes with regard to health service delivery. The objectives were to qualify and quantify the effect of undergraduate students on service delivery, and to understand the health service and academic factors that influence this effect. Rural sites outside metropolitan areas, where undergraduate health science students in medicine, physiotherapy, occupational therapy or speech and language therapy had been introduced up to a year previously, or were about to be introduced into district-level services, were purposively selected after negotiation with a range of stakeholders who relate to each teaching site administered by two different faculties of health sciences. The introduction of successive groups of students into the district-level health services varied at each site, depending on the types of students, their courses and logistics, and ranged from short repeated visits over a period of time to year-long ‘longitudinal’ placements.[7,10] Ten respondents in the health services were purposively identified by the researchers from each of the two faculties (N=20) to produce an adequate spread of information on the basis of their positions in the health services, their degree of involvement with students and their knowledge of the health system as determined by the researchers. Potential interviewees were contacted, and after consent was obtained, face-to-face semi-structured qualitative interviews were conducted in English by trained interviewers who were not directly involved in teaching, using a standard interview guide (Appendix 1). Interviews were audio recorded and transcribed verbatim. Additional notes taken by the interviewers were included in the data. Ethical approval for the study was obtained from the University of Cape Town Human Research Ethics Committee (ref. no. 453/2011), and permission was obtained from the Western Cape Government to conduct the study in its facilities. Analysis of the data was carried out independently by two researchers using an inductive approach to code major and minor themes according to the framework method,[11] then debating and discussing differences of interpretation and emphasis before deciding on the final codes, as well as their inter-relationships.

Results

During a period of 9 months in 2012, 7 participants were interviewed at one site and 9 at another site. These included 2 district managers, 2 hospital chief executive officers (CEOs), 1 operational manager, 3 medical managers, 2 family physicians, 3 hospital clinicians and 3 primary healthcare managers. Four potential respondents were not available at the time of the interviewers’ visits. Participants talked freely and interviews lasted between 30 and 60 minutes. The experience of accommodating undergraduate students on the service platform was described in terms of two opposing forces, i.e. the burden on and the benefit to service delivery. These were contributed to respectively by a number of different factors, which are described in more detail below. Three fundamental issues could tip the balance in favour of burden or benefit, as they determined the overall effect more substantially (Fig. 1). These ‘fulcrum’ issues were pivotal, and included the length of time of the

BENEFIT

BURDEN

Efficiency – extra pa ir of hands

Extra work to teach Student attitudes Orientation and ad

justment

Quality – students 'keep you on your toe s' Learning environmen t and staff morale Students have more time to listen

• Few v. many students • Short v. long rotations • Junior v. senior students

Fig. 1. A diagrammatic representation of the major themes.

student rotations, the seniority of the students and the number of students allocated to a particular site. Overall, taking all the data into account, the balance was assessed as marginally in favour of the benefit to service delivery of students on the platform, as directly articulated by two respondents: ‘They were also I would say more helpful than they were [a burden] or they saved us more time than they took time.’ (Family physician) ‘… they help us much more than they are a drawback.’ (Medical manager)

Fulcrum issues

Short v. long rotations Respondents clearly favoured longer student rotations: ‘The longer period that the students are placed here permanently, obviously is more beneficial for the different departments, they become part of the team and work as part of the team, whereas the small, the 2-week and 10-day rotations, they don’t have the time to become part of the team … So I prefer, and I think my departmental heads prefer the longer rotations here.’ (District manager) ‘But I think if they stay for a good while then it will have an impact, then they become useful as you’ve orientated them.’ (Family physician) ‘I think after 2 - 4 weeks they start adding to the service.’ (Family physician) Junior v. senior students Senior students were preferred over juniors: ‘They are final years, so they know a lot and have practical experience.

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Research They are far progressed from the junior grades, so they are very helpful. In that sense I would say they help us much more than they are a drawback.’ (Medical manager) ‘It’s been nicer with the say fifth-, sixth-year students. The fourth-year students tend to be, their knowledge is a bit less, so they tend to take more of your time to teach them, but it’s been positive so far.’ (Hospital clinician) Number of students A number of respondents made it clear that large numbers of students could overwhelm the clinicians, and reasonable limits need to be set on the maximum number of students at any one time at each health facility. The fewer the number of students, the more individual attention they would receive, and therefore the more responsibility they could take clinically under direct supervision. Large groups are difficult to co-ordinate, and they require dedicated management: ‘I think a critical mass is important – how many students per consultant or per department, and I know the university has mentioned or has got maybe bigger plans of the numbers and I have been … approached by the head of department at the tertiary institute to say well I want to send you more students, but we don’t have space. I just had to point blankly refuse, although I love to do it. I have mentioned that the time spent with them, it won’t be the same quality of time that we have seen up to now. So there is a critical mass which we will have to protect and … I am very hesitant to say that any student … more than three at a time in a department of our size will be positively affected, I think it will kind of, that’s about the limit we can handle.’ (Hospital clinician)

The burden of teaching

The extra work involved in teaching was described as follows: ‘… they help them and teach them but in the end it is my job to make sure they do their tasks, so that takes a lot of time.’ (Family physician) ‘… you feel responsible for them, so that in a sense it’s extra work … .’ (Family physician) In terms of understanding the burden of students on service delivery, there were three major themes that emerged from the interviews: the extra time involved in teaching, the orientation of new groups of students and negative student attitudes. Two minor themes also became apparent: students’ different learning styles and university demands. The time for teaching It is clear that students involve extra time, as explained by numerous respondents: ‘You have to think a bit more and explain more, so I think that is the biggest impact. It obviously takes extra time because you have to speak now, you can’t think of something, but I think that is the biggest impact by far.’ (Family physician) ‘It does mean you must go a bit slower because you must explain to the students, you must orientate them, you must tell them you see a patient there, I’ll see a patient here. You must go slowly around this, you must explain to them or they must present to you.’ (Family physician) ‘It just takes longer to do everything if you have students with you because you can’t just expect them to follow you around and absorb things. So

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when you have students with you, unless you ignore them, all of your activities do take a little bit longer.’ (Hospital clinician) Orientation and adjustment The initial period of orientation of new groups of students takes its own time: ‘… with any new project there is an adjustment phase and I think the irony, I mean it is the same period when the junior doctors, the community-service doctors also start. So the whole team could perceive or feel the burden of having more inexperienced team members, but as the year progresses the other doctors also catch on and the students become more and more confident.’ (Family physician) ‘I think the first day or two you have to show them where everything is, but once they are settled in, and that’s just a couple of days, then they are part of the team and they help a lot.’ (Family physician) Student attitudes Some of the students were perceived to have negative attitudes, or did not show enthusiasm: ‘We’ve had many like that who are not disciplined, they duck and dive, who you have to watch because it’s one thing I definitely don’t care about students, if they’re not there, I say to them they must start at 7:30, if you’re not there I’m not looking for you, but I’m not going report then that you’re gone.’ (Medical manager) ‘… not the SIs [student interns], I think they were fourth years or fifth years, some of them come here with an attitude, I just want to observe like in [tertiary hospital]. I know they are not here to work but sometimes you learn more if they do the thing physically themselves, but they don’t want to, they just want to observe.’ (Primary healthcare manager) Students differ Furthermore, students vary, and some struggle with self-directed learning styles: ‘I can just imagine if it is a student that isn’t really equipped for this kind of situation, where they need to do self-study. There is absolutely no way I will be able to supervise them and you know push them to every exam.’ (Family physician) ‘Some students come here with a lot of confidence, but they are more work than they save us time… .’ (Primary healthcare manager) University workshops take up time The demands of the university were mentioned by one participant: ‘One of the things that I find quite difficult is that we are quite often asked to attend workshops and so on by the university and I think that they actually don’t realise how pushed we are for time to get through the clinical work and so it is the sort of peripheral activities … from the university are also a significant use of time.’ (Hospital clinician)

Benefits

The benefits to service delivery of hosting students are summarised in four major themes: efficiency, quality of care, a learning environment and thoroughness. Three minor themes were also identified: teamwork, community involvement and rural career choices. Efficiency – an extra pair of hands Students are often regarded as part of the workforce:

Research ‘ … but having students for me I can say it is like having an extra pair of hands.’ (Operational manager) ‘… it makes the flow of patients and the work lighter because they come in the mornings, they help with ward work, see patients and then present patients.’ (Medical manager) ‘They basically just have to work with us and I mean that is just a boon for us.’ (Family physician) ‘So you usually don’t have to from scratch work through the patients yourself, you can just have a quick look and decide whether you’re going that way or whatever. So they save a lot of time seeing patients that you don’t have to repeat.’ (Medical manager) Quality of care – students ‘keep you on your toes’ The students retained the respondents’ interests in their field of expertise by challenging their thoughts: ‘You have to verbalise what you are doing and thinking, and that sometimes forces you to think a bit more because you have to explain it to a student.’ (Medical manager) ‘Keep you on your toes, yes, that is what they really do, they keep you on your toes.’ (Medical manager) ‘The doctors they are also now more alert.’ (Medical manager) ‘… it keeps me challenged; I have to organise my thoughts.’ (Hospital clinician) ‘When I have to suddenly take a history and examine a patient with a student around, that, terrible to admit it, but my professionalism doubles.’ (Family physician) Learning environment and staff morale The teaching and learning environment had a positive effect on staff morale: ‘The clinicians have to know what they are talking about because the students ask questions and they have got to know. So I think in general it uplifts the, shall I say, the knowledge base of the clinicians working in the hospital and it is good, it stimulates a type of a learning environment.’ (District manager) ‘So you are seeing in the same system, in-service training and student teaching. It must be integrated. [They are] not separate systems, you’re talking about one health system that has a teaching/learning component that can include students, not as separate entities but as part of the same thing.’ (Family physician) Students have more time to listen and be thorough ‘It is more efficient and quicker because they are more thorough, they work thoroughly, because they are learning they usually do it in order as it is supposed to be done.’ (Primary healthcare manager) ‘She had time to talk to this patient and she sat and she actually had a long discussion with her … if I say that quality could maybe come into it because students have more time, they’re not that pressurised to work through these patients quickly.’ (District manager) ‘… one student picked up a congenital anomaly on a baby … a newborn baby … that would have been missed if it wasn’t seen by one of the doctors.’ (Family physician) Teamwork ‘… it’s just one day you have to take time and show them everything and then they are part of the team, they are working with us … .’ (Medical manager)

‘ … so they get to be part of that clinical environment and I think also the community will then recognise them as being part of the team.’ (Family physician) ‘… whereby for us as nurses or for the whole team to function or to be functional is not a one-man show, it’s a team effort. So for them being around with us, or for them being here, it makes our workload easier or lighter.’ (Primary healthcare manager) Community engagement Students are involved in community projects that contribute to service delivery indirectly by focusing on prevention and health promotion: ‘Ja, ja they are involved with the community, whereby they initiate some projects. We have a project [in the] black community around here, whereby they have initiated the support groups; they run for the chronic patients whereby really if I walk around town they will be telling me that okay things are going well in the community because of their initiatives.’ (Operational manager) Rural career choices The long-term goal of attracting students to rural practice after they have graduated was articulated clearly: ‘… those situations and when they realise it is actually a very fulfilling job and they might, you know, go and work rural themselves.’ (Medical manager) ‘… and hopefully if it is part of the experience, they would choose to stay in the public sector, in a more rural setting.’ (Family physician)

Discussion

This study has outlined a number of key issues with regard to the effect of undergraduate students on district health services in SA. The major themes, as outlined in Fig. 1, give a snapshot of the balance in favour of a positive effect, depending on certain pivotal issues. It is clear from the data that the situation differs widely between different perspectives and sites, but the overall qualitative result is more in terms of benefit than burden, which is in accordance with the literature from other countries.[3,12,13] It could be argued that the burden and the benefit are not mutually exclusive categories, as every output requires some form of input. Furthermore, the factors contributing to either the burden or the benefit are not additive, as this was not a quantitative study. It would seem difficult to reduce all the major themes in these results to numbers, as the model in Fig. 1 might suggest, e.g. it is difficult to quantify, let alone directly compare, the general effect on staff morale and the stimulation of a learning environment against a factor such as the variety of student attitudes to learning. It was surprising how little attention was given to the eventual career choices of students, as this is one of the key motivations for initiating rural education platforms, but most of the respondents seemed to be more concerned with the immediate pressures of services rather than longer-term problems.[14-16] Nevertheless, the pivotal issues of the length of rotations, seniority of students and number of students at each site are quantifiable, and are clearly within the direct control of the faculties that send the students out; therefore, in the programme design, this balance can be actively negotiated and managed.[17] Some of the factors, such as the time required for teaching, could possibly be measured directly. The question of what length of time of a student rotation in a given health facility is enough to tip the balance in favour of service delivery, is indicated by some of the following results,

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Research e.g. one of the respondents mentioned that after the first ‘2 - 4’ weeks of orientation, final-year students start contributing to service delivery. This question of ‘How long is enough?’ deserves further research, preferably of a quantitative nature, as Worley and Kitto[18] have suggested that a hypothetical ‘turning point’ lies somewhere between 4 weeks and 5 months. While such a quantification has obvious pragmatic implications for curriculum design, it would align equally with a theoretical framing in terms of management sciences and educational theory, as it would enable student teaching to be accounted for in terms of its cost. As tertiary education generally becomes more managerial in its approach, this is an inevitable factor to consider in health professions education.

Study limitations

The limitations of the study include the small number of sites and respondents, but the inclusion of sites run by two different faculties contributes to the validity of the findings through triangulation: the data from the two sources were remarkably similar. The researchers, as academics from the faculties involved, recognised their bias in favour of the benefit of students to service delivery, and attempted to minimise this by recursive discussion of the data itself, staying close to what the respondents said. Similarly, the potential bias introduced by interviewers was counteracted by using a number of trained interviewers at different sites.

Conclusion

Undergraduate students can add benefit to health services if health professions educators plan their clinical rotations, recognising the pressures under which their clinical supervisors work to deliver services to patients. We recommend that health service managers and health professions educators collaborate closely and continually to optimise the benefit of hosting students on the district health platform for educational as well as service outcomes. Acknowledgements. This project was undertaken by the Collaboration for Health Equity through Education and Research (CHEER). The authors thank the interviewers and all the interviewees for their contributions to the study. Author contributions. SR and HC conceptualised the study together with members of CHEER, and DD-F collated the data. All three authors analysed the data, and SR drafted the manuscript, which all authors reviewed. Funding. The study was funded through a grant from Atlantic Philanthropies. Conflicts of interest. None.

1. Kirz HL, Larsen C. Costs and benefits of medical student training to a health maintenance organization. JAMA 1986;256(6):734-739. https://doi.org/10.1001/jama.256.6.734 2. Walters L, Worley P, Prideaux D, Lange K. Do consultations in rural general practice take more time when practitioners are precepting medical students? Med Educ 2008;42(1):69-73. https://doi.org/10.1111/j.13652923.2007.02949.x

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3. Price R, Spencer J, Walker J. Does the presence of medical students affect quality in general practice consultations? Med Educ 2008;42(4):374-381. https://doi.org/10.1111/j.1365-2923.2008.03016.x 4. O’Flynn N, Spencer J, Jones R. Does teaching during a general practice consultation affect patient care? Br J Gen Pract 1999;49(438):7-9. 5. Atuyambe LM, Baingana RK, Kibira SPS, et al. Undergraduate students’ contributions to health service delivery through community-based education: A qualitative study by the MESAU Consortium in Uganda. BMC Med Educ 2016;16(1):123. https://doi.org/10.1186/s12909-016-0626-0 6. Van Schalkwyk SC, Bezuidenhout J, Conradie HH, et al. ‘Going rural’: Driving change through a rural medical education innovation. Rural Remote Health 2014;14:2493. https://doi.org/10.3109/0142159x.2012.719652 7. Voss M, Coetzee JF, Conradie H, van Schalkwyk SC . ‘We have to flap our wings or fall to the ground’: The experiences of medical students on a longitudinal integrated clinical model. Afr J Health Professions Educ 2015;7(Suppl 1):119-124. https://doi.org/10.7196/AJHPE.507 8. Kraft R. Service learning. Educ Urban Soc 1996;28(2):131-159. https://doi.org/10.1177/0013124596028002001 9. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall, 1984. 10. Hudson JN, Poncelet AN, Weston KM, Jushnell JA, Farmer EA. Longitudinal integrated clerkships. Med Teach 2016;39(1):7-13. https://doi.org/10.1080/0142159x.2017.1245855 11. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117. https://doi.org/10.1186/14712288-13-117 12. Walters L, Prideaux D, Worley P, Greenhill J, Rolfe H. What do general practitioners do differently when consulting with a medical student? Med Educ 2009;43(3):268-273. https://doi.org/10.1111/j.1365-2923.2008.03276.x 13. Coleman K, Murray E. Patients’ views and feelings on the community-based teaching of undergraduate medical students: A qualitative study. Fam Pract 2002;19(2):183-188. https://doi.org/10.1093/fampra/19.2.183 14. Mathers J, Parry J, Lewis S, Greenfield S. What impact will an increased number of teaching general practices have on patients, doctors and medical students? Med Educ 2004;38(12):1219-1228. https://doi.org/10.1111/ j.1365-2929.2004.02014.x 15. Benson J, Quince T, Hibble A, Fanshawe T, Emery J. Impact on patients of expanded, general practice based, student teaching: Observational and quantitative study. BMJ 2005;331(7508):89. https://doi.org/10.1136/ bmj.38492.599606.8F 16. 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. 17. Wachter RM, Katz P, Showstack J, Bindman A. Reorganizing an academic medical service: Impact on cost, quality, patient satisfaction, and education. JAMA 1998;279(19):1560-1565. https://doi.org/10.1001/jama.279.19.1560 18. Worley PS, Kitto P. A hypothetical model of the financial impact of student attachments on rural general practices. Rural Remote Health 2001;1(1):83.

Accepted 15 September 2017.

Appendix 1. Interview guide 1. 2. 3. 4. 5.

7. 8.

Please tell me about your experience of undergraduate health science students in this sub-district. In your opinion, what is/will be/has been the impact of having students in this sub-district on the health services? Is it overall a positive effect, or a negative one? Why? Can you explain your opinion? Can you give examples? What do you think is the effect of having students here on: Human resources in the sub-district? Quality of care in the sub-district? Finances in the sub-district? Morale and motivation of health personnel? In your opinion, has there been any change in any of these aspects since students started coming here? (Note: in second round, refer back to first-round transcripts) How could any of these changes be measured and quantified? What documents or statistics could be used to track such changes?

Research

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

A new way of teaching an old subject: Pharmacy Law and Ethics S Chetty, BPharm, MSc, PhD; V Bangalee, BPharm, MPharm, PhD; F Oosthuizen, BPharm, MSc, PhD Discipline of Pharmaceutical Sciences, School of Health Sciences, Westville Campus, University of KwaZulu-Natal, Durban, South Africa Corresponding author: V Bangalee (bangalee@ukzn.ac.za)

Background. Pharmacy educators are responsible for ensuring that students are equipped with the necessary regulatory knowledge required to deal

with ethical challenges that arise in practice. Teaching methods have a strong impact on student learning, making it essential to determine how learning is influenced when changing pedagogy. Objective. To describe students’ experience and perceptions of the use of a case-based learning (CBL) activity as an adjunctive method to didactic teaching of pharmacy law and ethics. Method. A survey was conducted among 3rd-year pharmacy students enrolled for a Pharmacy Law and Ethics course at the University of KwaZuluNatal, Durban, South Africa. The course content was delivered didactically, followed by a CBL activity for which the students were divided into groups and assigned various real-life case studies. Results. Most of the 74 respondents (66%) agreed that the activity was enjoyable and metacognitively useful. A majority (77%) found the activity interactive, and 92% agreed that it enhanced their understanding of pharmacy law concepts. Eighty percent agreed that it facilitated their understanding of law and ethics concepts, and their application to real-life situations. Conclusion. The use of CBL was beneficial to both the individual student’s learning experience and the overall class learning process. More importantly, the exercise improved their metacognitive awareness, and suggests the need to consider this method of teaching as part of the formal curriculum to better equip students to deal with ethical issues that will arise in practice. Afr J Health Professions Educ 2018;10(1):61-65. DOI:10.7196/AJHPE.2018.v10i1.714

The status of pharmacy practice as a profession is governed by its laws and ethics, which underpin the role of pharmacists and confer upon them the exclusive authority to conduct certain activities that are restricted and unique to the profession. Knowledge and understanding of ethical issues and resolutions serve to guide decisions and behaviours inherent to a pharmacist’s practice. However, teaching pharmacy law has become increasingly challenging, as educators are constantly encouraged to find and implement innovative ways of teaching that will promote higher-order, critical thinking and collaborative learning, coupled with the need to increase student motivation.[1] Instruction in the main acts and regulations that govern the practice of pharmacy in South Africa (SA) are presented in a format that is outdated and difficult to interpret, which makes comprehension of the basic concepts challenging. Experience in teaching the module has revealed that the language or legalese in which pharmacy law policy is written is unfamiliar to pharmacy students, and is more suitable to law students. In addition, the acts are fragmented, creating further difficulty for students to draw on the different aspects of the law for rational decision-making, and for its application to real-life circumstances. This situation requires considerable effort and skill from the educator to teach students how to discern reasonable solutions to problems that they may encounter in practice. Previously, the various acts and regulations were taught to students in isolation via a predominantly didactic lecturebased format. This teaching method is often disconnected, and although lecturers try to link theory to application, it is difficult to do so by use of mere examples to illustrate the text. It also relies on the skills and expertise of the lecturer to maintain student attention for the duration of the lecture.

Students at the University of KwaZulu-Natal (UKZN), Durban, SA, are drawn from diverse backgrounds, bringing with them educational, communication and language barriers. In teaching this course, it became clear that students found the language of the law texts difficult to comprehend, interpret and apply. This created a fair amount of anxiety among learners, and called for the use of alternative teaching methods to enhance learning. However, no standardised strategies have been designed to effectively educate students and address the challenges in this area of instruction. One method could be to supplement traditional didactic lecture-based teaching with the development and implementation of case-based learning (CBL). CBL has been defined as an innovative, discussion-based teaching method[2] that is student centred, and encourages learners to interactively explore complex, realistic and specific situation scenarios.[3] CBL allows students to develop critical skills and reflective judgement through reading and discussing complex, real-life scenarios. It also promotes learner-centred small-group interactive learning experiences, as opposed to large-group didactic lecture-based teacher-centred instruction.[1] As a result, students involved in CBL tend to be more confident in practising the skills learnt during the process.[4] A further benefit that makes this method suitable for teaching in healthcare education is that it encourages students to view all aspects of a patient’s situation while handling a real case.[5] There are various types of CBL, which include seminars, standardised patient events, web situations, medical teaching rounds, mini scenarios and directed case studies.[4] The type of case study used depends on the aim of the course, the discipline being taught and the skills needed to be nurtured.

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Research At UKZN, a CBL activity was used to supplement the Pharmacy Law and Ethics course, which consisted of a series of didactic lectures. The study aimed to establish the usefulness of the exercise through a number of objectives, these being to explore the student’s experience and perceptions of the use of CBL, its perceived effectiveness for learning, aspects that they enjoyed/did not enjoy about the activity, benefits of the activity on learning, and finally, to obtain suggestions on how the activity could be improved.

Significance of the study

The requirement for an adjunct to routine didactic lectures has long been appreciated by higher education institutions. This stems from growing concerns that didactic teaching alone does not encourage the right student qualities, nor does it impart lifelong respect for learning.[6] In teaching Pharmacy Law and Ethics, educators are challenged to create an interesting and engaging method of educating students about a subject that is potentially considered to have little clinical relevance.[7] While CBL has been proven to have some success in meeting this challenge in other health professions courses,[6] there is a lack of documented data on its use in teaching pharmacy law and ethics in SA, and at UKZN specifically. Early evaluation of the usefulness of and learner experience with CBL is therefore important to modify and enrich the current teaching methods, and to form a better learning approach with the active participation of students.

Methods Context

The study involved all 3rd-year pharmacy students enrolled for the course entitled Pharmacy Law and Ethics (PHRM 355) at UKZN in 2015. Students enrolled in the course have limited exposure to pharmacy laws (they are introduced to the legal framework of the SA healthcare system in their 1st year of study), and generally have no previous exposure to ethical issues. Students registered for the course come from diverse backgrounds in terms of religion, language, ethnicity and self-directed learning skills. The course was developed to inform students of relevant legislation governing the practice of pharmacy. The regulatory content covered includes the Pharmacy Act 53 of 1974 and the Medicines and Related Substances Control Act (1963). In addition to law, students were introduced to Good Pharmacy Practice (GPP) standards; ethical principles, such as biomedical ethics; professional ethics; code of conduct; rules pertaining to the scope of practice of pharmacy personnel; and principles of medication scheduling.

Ethical approval

Ethical approval was obtained from the UKZN Humanities and Social Sciences Research Ethics Committee (ref. no. HSS/0354/015). Student consent was obtained prior to administering the questionnaire, with participation being voluntary and anonymity being maintained.

Current teaching method

The course has traditionally been taught via didactic lectures that introduce students to concepts, principles and their application. This has been an attractive approach for ease of information dissemination to increasingly large classes, as it allows for the economical use of staff time. However, this approach is largely teacher-centred, with minimal active interaction between lecturer and students, and between the students themselves.[6] It further places the burden of promoting learning almost entirely on the

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lecturer, and thus fails to develop opportunities to develop critical thinking among learners.

Intervention

The course content was first taught didactically and then supplemented by a CBL activity session. In this study, the 95 students were randomly divided into 11 groups of 8 or 9 students. The rationale behind the random placement of students into groups was to ensure that they mixed and shared ideas with their peers, irrespective of whether they had previously worked together. Each group was assigned a case study that reflected ‘real world’ ethical dilemmas that are seen in pharmacy practice. Each case included a brief overview that both established a context for the problem and identified major decisions that needed to be made. The cases required students to consider the problems from a perspective that necessitated analysis, with them being guided to suitable references to consult to solve the problem. An additional reason for modifying the structure of the course was to reinforce concepts covered in the didactic portion of the course with their application to real-practice situations. Groups were allocated 3 weeks to discuss and analyse the assigned cases, the activity being designed to encourage communication among the group members, while promoting engagement with the theory of pharmacy law. It was hoped that this type of interactive teaching would stimulate and maintain students’ interest, thereby allowing for greater participation of students in their own teaching programme. Students were required to search for relevant information to solve the case, provide supporting evidence and develop a 10 - 15-minute presentation to be delivered to the rest of the class during a tutorial session. During the presentations, the other groups were encouraged to ask questions, with discussions being concluded by the lecturer who confirmed correct answers or corrected group misconceptions. Overall group performance was assessed by the lecturer, and individual marks were adjusted based on the peer assessment of their individual contributions by their own group members.

Study design

This was a descriptive, observational study designed to report on students’ experience of the use of CBL as a teaching method. Data were collected through self-administered questionnaires that were manually distributed by the educator at the end of the day of group presentations. The structured questionnaire consisted of three sections, the first being demographic details (age, gender, highest qualification). Section 2 contained 9 closedended questions that were designed to establish their perceived value of the activity on improving comprehension, application to real-life situations, as well as metacognitive abilities. It consisted of Likert-scale questions focused on the following: (i) the student’s experience and perceptions of the activity; and (ii) its perceived effectiveness for learning. Section 3 consisted of open-ended questions that were thematically analysed and the responses aggregated to determine: (iii) what aspects students enjoyed or (iv) did not enjoy about the activity; (v) benefits of the activity on their learning; and (vi) suggestions for improvement.

Data analysis

Data were collected, captured electronically and processed using Microsoft Excel 2013 (Microsoft, USA). Descriptive statistics were generated and responses were tabled for the closed-ended questions, while the responses

Research for the open-ended questions were grouped in order of prevalence. The frequency count for common comments was determined and all the repeated responses (>10%) are reported.

Results

A total of 74 respondents (26 male, 48 female) from a class of 95 students completed the survey. The majority of students (64%) were between 21 and 22 years of age, and 71 (96%) indicated that a high school matric was their highest previous education. Table 1 reflects responses to the closed-ended Likert-scale questions. Regarding the student responses to Section 2 pertaining to experience and perceptions of the CBL activity, two-thirds (66%) agreed that they found the activity enjoyable, with 92% noting that it helped to improve their understanding of the law concepts. Eighty percent indicated that the activity helped them to understand and apply the concepts to real-life situations, while the majority (77%) agreed it was interactive, with many students (69%) reporting increased classroom involvement. Regarding the student responses to Section 2, pertaining to its perceived effectiveness for learning, just over half (59%) of the respondents agreed that they would rate learning high from this type of activity; however, less than half (46%) indicated that the activity kept them focused and motivated to learn more. Seventy-three percent agreed that the activity helped to validate their own learning, while 54% felt that the activity helped them to prepare for the examinations. The open-ended questions were analysed and separated into themes that were developed from the most frequent (>10%) responses (Table 2).

Discussion

The responsibility that pharmacy educators face in equipping graduates with enhanced communication skills, greater problem-solving capabilities, effective critical thinking abilities, and sound decision-making skills has become increasingly important.[8] This activity requires the use of innovative and pedagogically sound instructional strategies to facilitate the learning outcomes needed to practise in all aspects of the pharmaceutical profession. To the best of our knowledge, this study represents the first documented research into students’ perspectives on the use of CBL in the teaching of pharmacy law and ethics at UKZN. Student feedback regarding Section 2 on the experience and perceptions of the CBL activity and its perceived effectiveness for learning was generally

positive. Significantly, the majority (92%) of the students agreed that participation in the exercise helped to improve their understanding of law concepts, and many indicated that it helped them to appreciate how the various law and ethics concepts applied to real-life situations. This is encouraging, as the ability of students to attach a tangible value to the application of these scenarios to real-life situations is pertinent to the practice of pharmacy in SA. Most of the students agreed that the activity was interactive. The last four questions of the closed-ended questions explored the metacognitive responses of the students’ individual learning processes. The term metacognition was first used by Flavell, and means ‘thinking about thinking’.[9] Metacognition consists of two parts: knowledge of cognition and metacognitive regulation. The first part is the individual’s awareness of Table 2. Section 3: Open-ended questions Questions 3. Aspects enjoyed about the activity The activity was interactive and they learnt from the discussions Students found the activity enjoyable Students perceived value to it relating to real-life situations It promoted team activity and working together in a group 4. Aspects least enjoyed about the activity Nothing to report Working in groups and some members of the group did not contribute The presentations were too long 5. Benefits of case-based learning It promoted retention of information Application to real-life situations increased comprehension and understanding of the law concepts It promoted learning in a different way 6. Students’ suggestions to improve the activity Students should be allowed to choose their own groups

Responses, % 31 23 19 13.5

22 22 9.5 41 38

12 28

Students would like more examples and scenarios No suggestions

26 15

Table 1. Section 2: Closed-ended questions Questions 1. Experiences and perceptions of the activity I found this activity enjoyable This activity helped improve my understanding of different law concepts The activity helped in my understanding of the application of various concepts in law and ethics to real-life situations I found this activity interactive This activity increased my involvement in the classroom 2. Perceived effectiveness for learning I would rate my learning high from this type of activity This activity helped me stay focused and motivated me to learn more This activity helped me validate my own learning The activity helped in preparation for my examination

Agree, %

Neutral, %

Disagree, %

Skipped question, %

66 92 80

31 7 15

3 1 1

0 0 4

77 69

20 24

1 7

2 0

59 46 73 54

35 46 27 39

4 8 0 6

2 0 0 1

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Research themselves as a learner and which study method would make them more productive. The second part refers to strategies that the student employs to monitor and enhance their own learning.[10,11] The questions in the survey probed the students’ self-awareness of the activity and their perceived impact on individual learning and preparation for examinations, with two-thirds enjoying the use of this type of activity to aid their learning process. More than half of the students were cognisant that they found learning high from this type of activity. The neutral numbers were quite high in this section, which could mean that people have different ways of learning, but that with this way at least there are more opportunities for learning than the traditional way, and more students will graduate with improved understanding. Section 3 consisted of four components, aspects they most and least enjoyed, their opinions of the benefits of CBL, and suggestions for improving this method of learning, all of which were thematically analysed owing to the nature of the open-ended questions. This feedback was valuable for future modification and tailoring of the activity to suit the targeted students and course. Regarding issues relating to their enjoyment, a common response was that they found the activity enjoyable and interactive, working together in a group and benefited from the discussions. From an educator’s perspective, group work also encourages co-operative learning, where the educator becomes the facilitator rather than the expert, their role being to guide learners towards achieving their goals.[12] One of the fundamental aspects of teaching in the pharmacy discipline is to ensure that students achieve certain core graduate competencies, one of these importantly being the ability to collaborate and communicate in a group or team. As future healthcare practitioners, their ability to function professionally, inter-professionally and in trans-professional teams will be essential. Ideally, students upon graduation from UKZN should be respectful of individual and cultural differences, backgrounds and orientations. They should also possess the ability to prevent, negotiate and resolve interpersonal conflicts.[13] This exercise afforded students this opportunity, to work in teams and be sensitised to the implications of working with different personalities and dynamics. It was envisaged that working in randomly selected groups would facilitate discussion, debate and the sharing of ideas to solve a problem. During case analysis, students work together to discover what they know, as well as what they needed to know about the case, thus leading to more creative resolutions. In addition, students are more open to the ideas of their fellow peers during a CBL discussion.[14] As indicated in Tables 1 and 2, a number of students found group work and learning from others enjoyable. Contrary to the above, group work was also found to be a theme that students did not enjoy about the activity. As in any group, friction and frustration are bound to arise when individuals are required to work together, particularly when they are randomly assigned. Some students voiced concerns about fairness, and complained about being awarded the same mark, as members of the group did not contribute equally to the activity. The use of peer assessment of their group members was used in an effort to counter this bias.[15] In hindsight, this activity would benefit from developing a set of initial ground rules and perhaps appointing a group leader to ensure that these rules are adhered to with regard to student contribution, attendance of meetings and completion of allocated member activities.[16] A suggestion that also emerged from the open-ended

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questions on how to improve the activity focused on dissatisfaction with the groups, where students suggested choosing their own groups. Another factor that hindered student enjoyment of the task was the lengthy nature of the presentations. Although students were given a stipulated time of 10 - 15 minutes per presentation, many groups exceeded this, which created the problem of poor concentration. To overcome this in the future, more stringent time-keeping will be applied, and students will be provided with instruction on how to estimate and prepare for presentations with time limits. Responses to the open-ended question that probed the benefits of the activity for learning, included that it promoted greater retention of knowledge. The literature has shown that the process of CBL allows the student to build new knowledge based on what they have previously learnt, meaning that they can access previous knowledge related to the case and, with further effort, find the answer.[2] This self-discovery improves their retention, as opposed to them memorising facts or lecture notes.[2] In addition, the students felt that they learnt from the discussions that were generated on the topic. They also perceived value in the application of the law to real-life situations, indicating that case studies based on real-life situations also promote the use of course content knowledge, and improve decision-making and knowledge retention. The activity was also intended to make learning enjoyable and interactive, thereby allowing students to take more ownership for their own learning and not merely be passive participants. From Edgar Dale’s[17] cone-ofexperience model, it is theorised that people tend to retain knowledge more productively if they were contributors rather than mere observers. According to Dale’s model, in a lecture, people tend to recollect ~10% of what they read, 20% of what they hear, 30% of what they see, 50% of what they see and hear, 70% of what they say and write, and 90% of what they do, i.e. actively participate.[17] One of the themes that emerged from the openended section relates to the value of the activity for learning, as it promoted learning in a different way, using visual and verbal methods and not only reading. Active learning is a process by which students are participants in their own learning process. Different approaches to active learning include co-operative, problem-based, team-based, case-based, ability-based and assessment-based learning.[18] Dividing students into groups and assigning them real-life problems to solve and to present to the class tap into the teambased learning and CBL approaches.[18] Although not one of the core objectives of the study, it was ascertained that an additional core competency that was gained in the study was communication skills. Developing communication competencies in the pharmacy curriculum should not be limited to teaching counselling and interpersonal skills, but should also enable students to foster confidence in developing public speaking. Presenting their findings to their peers provided students with the opportunity to practise their public-speaking skills in a safe and supportive setting.[19] At a national level, accreditation bodies have recommended a paradigm shift from instructional to learning-based teaching.[13] The ‘instructional paradigm’ or ‘talk to chalk’ is primarily a lecture-based one-way flow of information, whereas in the ‘learning paradigm’, students partner in the creation of learning. It facilitates students taking responsibility for their own learning and makes them more independent thinkers.[20] SA pharmacy law entails the teaching of a large subject content, with the acts and regulations often being written in isolation, which makes it difficult to understand their

Research application. During this exercise, students were encouraged to engage with the literature to find plausible solutions from within SA law texts. Students’ responses revealed that the use of the case studies made them search for answers, and in so doing, research a topic further.

Study limitations

The study reported on student experience of CBL to teach the 3rd-year Pharmacy Law and Ethics course module; hence, the true appropriateness of incorporating CBL either as a replacement or in conjunction with didactic lecture-based teaching for other modules remains unclear. The second limitation was that the study did not assess the effectiveness of using CBL as a supplement to didactic teaching. This would have helped to ascertain if this blend of teaching would enhance learning outcomes appropriate for this particular institution in terms of subject matter and student composition.

Recommendations

This research would benefit from further studies exploring the relationship between the use of CBL and results from student assessment grades to better determine the impact of this teaching strategy. In addition, exploring the reasons for those who did not find it beneficial needs to be established in terms of school background and preparedness of independent and critical thinking.

Conclusion

The results of the study regarding the experience of using a CBL activity to teach an aspect of Pharmacy Law and Ethics reveal that this teaching strategy is perceived as a useful adjunct to the traditional didactic teaching of this subject. The student feedback suggests that CBL has a role to play in enhancing learning, and that understanding the reasons for some students not feeling that it added to their learning experience would be a valuable tool to teaching law and ethics to future pharmacy students, this being essential to prepare them to deal with ethical challenges that arise in practice. Acknowledgements. The authors are thankful to Ms Carin Martin for all her invaluable advice and editorial support. Author contributions. SC was responsible for the conceptualisation, data collection and write-up of the article. VB and FO assisted in data analysis and the final write-up of the manuscript.

Funding. The research reported in this publication was supported by the Fogarty International Center (FIC), National Institutes of Health (NIH) Common Fund, Office of Strategic Coordination, Office of the Director (OD/OSC/CF/NIH), Office of AIDS Research, Office of the Director (OAR/NIH), and National Institute of Mental Health (NIMH/NIH) of the NIH under Award Number D43TW010131. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Conflicts of interest. None. 1. Jesus A, Cruz A, Gomes MJ. Case based, learner centered approach to pharmacotherapy. Proceedings from EDULEARN11 Conference, 4 - 6 July 2011, Barcelona, Spain. https://repositorium.sdum.uminho.pt/ bitstream/1822/12772/1/edulearn11-2.pdf (accessed 9 November 2017). 2. Hale S. Politics and the real world: A case study in developing case-based learning. Eur Polit Sci 2006;5(1):8496. https://doi.org/10.1057/palgrave.eps.2210060 3. Chi-Wan LY, Lopez-Nerney S. Using case-based learning to enhance awareness of communication principles: An exploratory study. Reflect Engl Lang Teach 2005;4:47-65. 4. Thistlethwaite JE, Davies D, Ekeocha S, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 2012;34(6):e421-e444. 5. Richards PS, Inglehart MR. An interdisciplinary approach to case-based teaching: Does it create patient-centered and culturally sensitive providers? J Dent Educ 2006;70(3):284-291. 6. Osinubi AA, Ailoje-Ibru KO. A paradigm shift in medical, dental, nursing, physiotherapy and pharmacy education: From traditional method of teaching to case-based method of learning – a review. Ann Res Rev Biol 2014;4(13):2053-2072. https://doi.org/10.9734/arrb/2014/9053 7. Bess DT, Taylor J, Schwab CA, Wang J, Carter JA. An innovative approach to pharmacy law education utilizing a mock board of pharmacy meeting. Innovations Pharm 2016;7(1):9. https://doi.org/10.24926/iip.v7i1.419 8. Fisher RC. The potential for problem-based learning in pharmacy education: A clinical therapeutics course in diabetes. Am J Pharm Educ 1994;58(2):183-189. 9. Flavell JH. Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry. Am Psychol 1979;34(10):906-911. https://doi.org/10.1037//0003-066x.34.10.906 10. Lai ER. Metacognition: A literature review. 2011. images.pearsonassessments.com/images/tmrs/Metacognition_ Literature_Review_Final.pdf (accessed 9 November 2017). 11. Livingston JA. Metacognition: An overview. 1997. http://www.gse.buffalo.edu/fas/shuell/CEP564/Metacog.htm (accessed 9 November 2017). 12. Bitzer E. Cooperative learning. In: Gravetts S, Geyser H, eds. Teaching and Learning in Higher Education. Pretoria: Van Schaik, 2004. 13. Health Professionals Council of South Africa. Core competencies for undergraduate students in clinical associate, dentistry, and medical teaching and learning programmes in South Africa. Pretoria: HPCSA, 2014. 14. Waterman MA, Stanley ED. Investigative case-based learning: Teaching scientifically while connecting science to society. Invention and impact: Building excellence in undergraduate Science, Technology, Engineering and Mathematics (STEM) education, successful pedagogies. Am Ass Adv Sci 2004:55-60. 15. Tollefson E. Evaluating peer contributions to group work. MA thesis. New York: West Point, Center for Faculty Excellence, US Military Academy, 2015:1-11. http://www.usma.edu/cfe/Literature/Tollefson_15.pdf (accessed 8 February 2018). 16. Haworth IS, Eriksen SP, Chmait SH, et al. A problem based learning, case study approach to pharmaceutics: Faculty and student perspectives. Am J Pharm Educ 1998;62(4):398-405. 17. Dale E. Audio-Visual Methods in Teaching. New York: Dryden Press, 1946. 18. Gleason BL, Peeters MJ, Resman-Targoff BH, et al. An active-learning strategies primer for achieving abilitybased educational outcomes. Am J Pharm Educ 2011;75(9):186. https://doi.org/10.5688/ajpe759186 19. Luiz AJA, Zeszotarski P, Ma C. Developing pharmacy student communication skills through role-playing and active learning. Am J Pharm Educ 2015;79(3):44. https://doi.org/10.5688/ajpe79344 20. Barr R, Tagg J. From teaching to learning: A new paradigm for undergraduate education. Change 1995;27(6):13-26. https://doi.org/10.1080/00091383.1995.10544672

Accepted 12 September 2017.

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Research

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

Transition-to-practice guidelines: Enhancing the quality of nursing education T Bvumbwe,1 PhD; N Mtshali,2 PhD 1

Department of Nursing and Midwifery, Faculty of Health Sciences, Mzuzu University, Luwinga, Malawi

School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: T Bvumbwe (bvumbwe.tm@mzuni.ac.mw)

Background. A de-link between initial training and transition to practice has been reported. Effective transitioning to practice enhances competences and confidence among newly graduated nurses. Objectives. To develop transition-to-practice guidelines as a tool to complement efforts to improve nursing education in Malawi. Methods. A multi-method design was used within the framework of the Stufflebeam context, input, process, product (CIPP) model. Analysis of reports from a nursing conference derived four core concepts, highlighting the context within which goals for transition-to-practice guidelines needed to be focused on. A panel discussion suggested guidelines based on these concepts. Review meetings and a review of the literature, local policies and standards were conducted to provide input to enhance credibility and reproducibility of the proposed guidelines. Consensus workshops involving nurse educators, nursing clinical preceptors, nurse practitioners and policymakers were conducted as a process evaluation for the guidelines. Results. Four core concepts emerged from the process of guideline development. Eleven guideline statements were formulated as a product of the guideline development process. Although newly graduated nurses are exposed to various clinical settings during college training, nursesâ&#x20AC;&#x2122; skills and clinical judgement are still rather weak and need more formal support. The guidelines provide assistance for transition to practice among newly graduated nurses. Conclusion. Nursing education is a complex process that starts at student recruitment and should effectively progress until transition to practice. Transition-to-practice guidelines to complement other guidelines in nursing education are timely in Malawi. Afr J Health Professions Educ 2018;10(1):66-71. DOI:10.7196/AJHPE.2018.v10i1.898

There is global consensus that the performance of a healthcare system largely depends on a competent nursing and midwifery workforce. Nurses form the backbone of the healthcare system and are a universal access point for almost 80% of healthcare users, especially in primary healthcare settings. However, nurses continue to face challenges in the 21st century, which are more complex and have changed healthcare delivery, especially in poorresource settings. Globally, there is an increased demand for an efficient and effective nursing workforce. Evidence shows that, despite the increasing complexity of nursing practice, there is a wide gap between theory and practice.[1] Clinical education remains central to the nursing curriculum and forms the foundation for bridging the gap between theory and practice. Clinical education prepares nurses for skills and competences to effectively provide safe, quality care in complex settings.[2] In Malawi, there are reports of poor competences and negative attitudes of nurses towards patients and nursing care. Therefore, nursing education falls short of the expectation to produce sufficient and well-trained nurses.[3] Missen et al.[4] reported that inadequacy in the preparation of nurses for practice is a worldwide problem. A de-link between initial training and transition to practice has been reported in many setting.[5] Effective transition to practice enhances socialisation, and improves competences[6] and confidence among nurses. Spector et al.[7] indicated that hospitals that use established transition programmes reported higher retention rates. Nurses also reported fewer patient errors, employed

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fewer negative safety practices, and had lower stress levels and better job satisfaction. It is against this background that we developed transition-topractice guidelines in nursing.

Assumption underlying the guidelines

The transition-to-practice guidelines are built on the assumption that training of nurses is a complex process. Its outcome is based on an interactive relationship between academic theory and practice, which is well regulated at all stages. The task to narrow the theory-practice gap requires a co-ordinated process between academic and practice settings, which strengthens the ability of newly graduated nurses to perfect what they have learnt in training institutions in complex practice settings.

Purpose of the guidelines

Transition to practice of new graduates forms a critical component of the overall nursing education process. Well-developed transition-to-practice programmes ensure a competent nursing workforce that is adequately prepared to deliver within a complex healthcare system. Transition guidelines will help to increase nursesâ&#x20AC;&#x2122; confidence and competences, increase patient safety and improve overall quality of nursing care in Malawi. The guidelines will support formal programmes that are designed to assist progression of newly graduated nurses from training to practice. The purpose of this work was therefore to develop guidelines for transition to practice as a tool to complement nursing education in Malawi.

Research Guidelines stakeholders

The training of nurses is a complex process that starts at recruitment into a nursing programme and progresses to continued professional development throughout their working life. This complex process overlaps with various environments and various stakeholders. The latter are individuals who take a participatory role in the training of nurses and include the student, nurse educator, regulatory body and healthcare institution.

Nursing educator

Nurse educators align nursing curricula to the practising needs of the nursing students. The nurse educator imparts knowledge to nursing students, who use it to perfect their practising skills and competences.

Regulatory body

The regulatory body stipulates various scopes of practice and expected competency levels that a newly graduated nurse should achieve to be certified as safe and competent to practise. This body regulates nurse education and practice, and both have to be aligned in the preparation of the new nurse.

Healthcare institution

Healthcare institutions have a unique culture in which the new graduate has to adapt to ensure efficiency and effectiveness in delivery of quality services. The nurse manager’s task is to ensure that new graduates increase their performance to achieve health goals for healthcare users.

Newly graduated nurses

A newly graduated nurse is a key stakeholder at the centre of an interactional relationship among healthcare institution, regulatory body and nurse educator.

Guidelines development process

A multi-method design was used for the development of the transition-to-practice guidelines (Fig. 1). Initially, reports from a national nursing education research conference in 2015 were analysed using thematic analysis to propose core concepts. Table 1 summarises research reports that were presented during the conference. Four core concepts were derived from analysis of the reports. On the last day of the conference, 8 nursing experts were invited

National nursing education research dissemination conference – research report analysis

Expert discussion – academia (n=3); practice (n=3); policymakers (n=2); regulatory bodies (n=1)

NEPI review meeting – national technical group (n=4); nurse educators (n=12); nurse managers (n=8); clinical preceptors (n=8)

Draft guidelines formulation – guidelines (n=15)

Literature review, review of local policies/ standards, descriptive and exploratory studies

2nd NEPI review meeting – nurse educators (n=13); policymakers (n=5); clinical preceptors (n=8); practitioners (n=15)

Review and revise draft guidelines

Delphi 1st round – nurse educators (n=10); nurse practitioners (n=10)

Review and revise

Delphi 2nd round Review and revise Delphi 3rd round

Final review and endorsement - 4 core concepts - 11 guidelines

Review and final guidelines draft

Fig. 1. Process of guidelines development for transition to practice. (NEPI = Nursing Education Partnership Initiative.)

to a panel discussion based on their specific expertise in nursing education and clinical practice to discuss the reports. Table 2 presents demographic characteristics of participants during the expert discussion. The discussion was open and guided by two questions followed by probes: ‘What is your comment about the quality of nursing education in Malawi based on the research reports presented during the conference?’ and ‘What recommendations would you give to improve nursing education?’. Context evaluation by means of the panel discussion determined goals that would be addressed by the transition-to-practice guidelines. Context evaluation described the current state of the nursing education gap. A Nursing Education Partnership Initiative (NEPI) project gathered members of the NEPI

technical working group (n=4), nurse educators (n=12), nursing managers (n=8) and nursing clinical preceptors (n=8) from teaching hospitals to review strategies being implemented to improve nursing education in Malawi in view of the outcome of the expert discussion. The panel of experts and those at the review meetings discussed the core concepts derived from the nursing education conference. Key points were summarised and draft transition-to-practice guidelines in nursing education were formulated. The draft guidelines then guided a review of local policies and nursing education standards. A review of the literature and a descriptive exploratory study were conducted to contribute towards an input evaluation to enhance credibility and reproducibility of the proposed guidelines. The guidelines were then discussed

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Research Table 1. Summary of research reports for the nursing education research conference Core concepts Academic clinical collaboration

Research report Where is the grade coming from? Problems and challenges in evaluating the clinical performance of nursing students

Registered nurses’ experiences with the clinical teaching environment in Malawi

Can research improve nursing and midwifery education in Malawi? (Keynote address) Evidencedbased practice strengthening

Theory-practice gap reduction

Patient-centred care in nursing and midwifery education

Strategies for the implementation of clinical practice guidelines in intensive care: a systematic review Involvement of registered nurses in clinical teaching of nursing students in central hospitals in Malawi

Assessing quality of the clinical learning environment for nursing and midwifery students in northern Malawi

Clinical teaching in clinical situations An investigation of stressors among Malawian nursing and midwifery students Innovations in nursing training

Enhancing students’ moral competence in practice: challenges experienced by Malawian nurse teachers Exploring knowledge and perceptions of tutors of the use of a problem-based learning approach in Christian Health Association of Malawi nursing colleges Factors affecting clinical performance of nursing and midwifery technician students at three nursing colleges in southern Malawi Teaching and learning methodology in nurse/midwife education

Knowledge and attitudes of nursing and midwifery learners and educators towards self-directed learning in Malawi

and reviewed in a consensus workshop. Nurse educators (n=13), nursing clinical preceptors (n=8), nurse practitioners (n=15) and policymakers (n=5) participated in the workshop to provide information that can be used to guide the implementation of the guidelines, procedures and activities, as well as being a means to identify successes and failures. Consensus procedure followed the reviews and involved three rounds of Delphi stages. First, Delphi involved nurse educators (n=10) and nurse

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Key findings Evaluation of students’ clinical performance is a vital component of nursing education; it should be conducted in a manner that effectively determines students’ clinical proficiency. Students become preoccupied with building relationships with clinical nurses to obtain good grades Clinical teaching and learning inadequately prepares students for practice owing to challenges of inadequate faculty support, poor clinical learning environment, poor competence among nurses and unsupportive working conditions Evidence-based practice requires that both nurse educators and nurse practitioners engage in collaborative research. Research builds on knowledge for nurses Quality of nursing care improves when care is based on objective assessment of patients’ needs. Nursing education emphasises evidencebased provision of nursing care Practice guidelines strengthen provision of quality care to the patient in the intensive care unit Registered nurses possess adequate experience regarding practice. Their involvement increases changes for narrowing a theory-practice gap that exists owing to lack of integration between what students learn in class and what happens in practice settings The nature of the clinical learning environment has a direct impact on the achievements of the clinical learning outcomes. However, the clinical learning environment is characterised by a lack of resources, poor faculty support, and a lack of collaboration between academia and practice in training students Students learn better in clinical situations that provide adequate support from clinical personnel Clinical learning is stressful for students owing to the nature of the clinical learning environment, especially for newer students. With time, students adapt to the challenges of the clinical environment A less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. Students develop moral competence when they are given an opportunity to reflect Nurse educators need capacity building in teaching approaches to promote achievement of learning outcomes among students Students’ clinical performance is affected by a poor clinical learning environment. Nurses’ attitude towards students, availability of faculty support during clinical practice and lack of resources are important aspects of a clinical learning environment Use of various methods in teaching enhances acquisition of knowledge and skills by nurses. Clinical mentorship increases the chance for students to learn during practice Adequate orientation of students towards teaching approaches increases their positive attitude towards these approaches

practitioners (n=10) to explore their opinions on the guidelines. Results from the first round of the discussion informed a questionnaire for the last two Delphi stages. The researcher (TB) reviewed and produced a final draft of the guidelines, which was presented to an education committee for approval as the final product of the guideline-development process. Table 3 presents final transition-to-practice guidelines that were developed by means of the abovementioned process.

Research Table 2. Characteristics of panel discussion experts Characteristics Gender Male Female Age, years ≤30 31 - 40 ≥41 Education qualification Bachelor Master PhD Length of service, years ≤5 6 - 15 ≥16 Publications, n 0 ≤2 ≥3

Nurse educators

Nurse practitioners

Policymakers

Regulatory bodies

1 2

2 1

3 -

1 2 -

2 -

1 -

1 2

1 2 -

1 1

1 -

Table 3. Guidelines for transition to practice in nursing education Core concept 1: Academic clinical collaboration Transition-to-practice programmes should show evidence of collaboration between training and practice institutions Transition-to-practice programmes should be implemented in liaison between co-ordinators of the transition programme from both training and practice institutions Core concept 2: Evidence-based practice strengthening Academic and practice settings should mutually engage to develop innovative ways to support transition of newly graduated nurses Newly graduated nurses should undergo a formal performance appraisal by responsible mentors from the hosting practice institution and nurses’ training or linked college Core concept 3: Theory-practice gap reduction A formal transition-to-practice programme that meets the expected learning outcomes of new graduates should be approved by the Nurses and Midwives Council of Malawi All students entering the transition-to-practice programme should show evidence of fulfilling minimum requirements for completion of the nursing training programme Transition to practice should be done at health institutions that meet the minimum set standards for clinical training placement Newly graduated nurses should be engaged within the first 6 months after graduation, as this is considered a critical period that needs transition support for nurses to consolidate what they learnt while in college Core concept 4: Innovation in nursing training approaches All registered nurses should be trained as clinical preceptors to support clinical mentorship of newly graduated nurses Transition to practice should be done under supervision of a trained preceptor Transition to practice is considered as a period for orientation, preceptorship and specific professional development that allows personal and professional growth

Guidelines development process: Outcome and discussion

The national nursing education research conference comprised 18 research reports and 1 keynote speech. Before the conference, abstracts were independently assessed for inclusion by a Norwegian Church Aid conference committee. Four core concepts within the context evaluation of the research reports emerged and included academic and practice collaboration,

evidence-based practice strengthening, theory-practice gap reduction and innovations in the approach to the training of nurses, derived from analysis of the reports. Draft guidelines for transition to practice were developed from these four core concepts.

Core concept 1: Academic and practice collaboration

The nursing curriculum needs to be aligned to the clinical setting to ensure

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Research that graduates are equipped to face the challenges of a complex and dynamic healthcare delivery system. Greenwood[8] argued that the effectiveness of qualified nursing graduates should become the responsibility of both the training institutions and clinical practice. Expert review revealed that preparing a sustainable, competent nursing and midwifery workforce is a shared responsibility between academia and the practice setting. Some participants highlighted the following: ‘… a nurse will never be fully produced by training institutions without practice institutions.’ (AC, Nurse educator) ‘Training for practice requires that those trained should practise within the practice settings that embrace theory and practice integration.’ (TL, Nurse regulator) Academic-practice collaboration is an important mechanism for strengthening nursing education, practice and research. Despite the increasing effort to bridge the theory-practice gap, the lack of formal partnerships between academia and practice leads to disintegrated efforts in the improvement of nursing education in Malawi. Data collected from consensus meetings indicated that the guidelines that were developed put in place measures to ensure that academic and practice settings work collaboratively towards a competent and efficient nursing graduate (Table 1). There is hope for an improved nursing education system in Malawi if nurse educators and practitioners understand and appreciate the academicpractice partnership, its benefits, elements and challenges. Lack of a transition-practice programme exposes new nurses to the loss of the nursing education support system. During guideline review meetings, participants highlighted the importance of maintaining college support during the transition period. Duchscher[9] reported that if new nurses do not have immediate access to previous educators to provide intellectual counsel, emotional support, practice consultation and feedback, feelings of isolation and self-doubt increase. Access to support from peers and colleagues is reported to be an important link for nurses’ development. A participant indicated that: ‘… the mentorship programme will expose newly graduated nurses to an environment with appropriate support from experienced nurses.’ (GC, Policymaker) Nurse educators could take a leading role in designing curricula for transition programmes.

Core concept 2: Evidence-based practice strengthening

Evidence-based nursing promotes the use of contemporaneous recent research findings as the basis for clinical decisions.[10] The newly graduated nurse must develop cognitive and emotional knowledge and technical skills and be able to apply this knowledge in practice. This will help nurses to make well-grounded decisions and deliver evidence-based nursing. Findings of this study highlight that new nurses must be able to synthesise evidence-based information with critical thinking skills. Transition-topractice programmes should support an understanding of the importance of quality care and of their role in the continuum of care among new nurses. For quality care provision, newly graduated nurses have to develop the clinical judgement that experienced nurses possess: ‘… the process of transition exposes the newly graduated nurses to practice culture that the newly graduated gets socialised into.’ (ET, Nurse educator)

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Opinions from consensus discussions showed that newly graduated nurses discover the practical knowledge that is necessary for clinical judgement as they undergo transition programmes. Expert discussion revealed that clinical decisions should be evidence based and that an understanding of the knowledge sources that newly graduated nurses use is important to safeguard quality of care. Voldbjerg et al.[11] argued that, during the transition phase, feelings of confidence and ability to use critical thinking and reflection have a great impact on knowledge sources incorporated in clinical decisions.

Core concept 3: Theory-practice gap reduction

The literature shows a mismatch between nursing theory and practice.[12] Differing perspectives exist between nurses in the practice sector and those in the education sector with regard to the practice readiness of new graduates. Wolff et al.[13] recommended a shift in the discourse around practice readiness, whereby nurses from all sectors should focus on unique, innovative and co-operative solutions to ensure the effective transition of all nursing graduates in the 21st century healthcare system. Wide gaps in theory and practice among new nurses are being reported.[14] Consensus discussion pointed out that transition-to-practice programmes help to reduce the gap between what students learn in class and what is expected of them in practice: ‘Newly graduated nurses need a period of orientation to real practice. This helps them integrate into practice what they learn during training.’ (TN, Nurse practitioner)

Core concept 4: Innovations in the training of nurses

There was strong argument from the consensus discussions that initial experiences of graduates can shape the development of nurses during their careers. Findings of the study indicated the critical importance of welcoming the new nurse into an inquisitive, supportive environment, where good staff relationships flourished. This is consistent with Spector et al.’s[7] report, which highlighted that transition-to-practice programmes that included patient-centred care, communication and networking, quality improvement, evidence-based practice, informatics, safety, clinical reasoning, feedback, reflections and specialty knowledge in an area of practice provided better support for newly graduated nurses. Data from a panel of experts indicated that preceptorship proved to be an essential and possible way to start as a new nurse. There was a general understanding in the consensus meetings that preceptors provide a supportive environment for new nurses to develop their confidence as independent professionals and refine their skills, values and behaviours. Matua et al.[15] noted that having expert support and learning from best practice give new nurses a foundation for lifelong learning through professional feedback. Studies showed that supportive behaviour and constructive feedback from qualified nurses and involvement of newly graduated nurses in all aspects of decision-making during care provision are important features that assist in developing the new nurse. Newly qualified nurses become well aware of their inexperience. General feedback from the data showed that the guidelines therefore highlight the need for effective preparation of preceptors to fill this important role and help new graduates develop their skills and competences: ‘… registered nurses need to be equipped with knowledge and skills to take newly graduated nurses through a transition process that allows innovation and creativity. (GC, Policymaker)’

Research Conclusion and implications for nursing education

Nursing education prepares a sufficient number of highly qualified nurses, who are necessary for the complex healthcare demands. A key concern of nurse educators is preparing graduates for practice. Findings of our study showed that transition to practice has not been adequately addressed in Malawi. New nurses require adequate support because they face a new environment, new expectations and new roles when they join a practice. These guidelines offer a direction on how transition to practice could be conducted in Malawi to ensure effective preparation of newly graduated nurses for practice. The guidelines complement the existing standards in guiding nursing education practice. Proper transition-to-practice programmes are significant for new graduates’ professional growth.

Study limitation

There is one limitation to this study that needs to be addressed. Malawi plans to introduce an internship programme for nursing training programmes. These guidelines may serve the same purpose. Consensus should be reached to have either a transition-to-practice programme or an internship programme. One general name needs to be adopted for the programme. Acknowledgements. Thanks to all nurses who participated in the study. Author contributions. TB conceptualised the study and collected the data. TB and NM analaysed the data and drafted and approved the final manuscript.

Funding. The study was supported by ICAP through a NEPI. Conflicts of interest. None. 1. Ajani K, Moez S. Third World Conference on Educational Sciences – 2011 gap between knowledge and practice in nursing. Procedia Soc Behav Sci 2011;15:3927-3931. https://doi.org/10.1016/j.sbspro.2011.04.396 2. Wells L, McLoughlin M. Fitness to practice and feedback to students: A literature review. Nurse Educ Pract 2014;14(2):137-141. https://doi.org/10.1016/j.nepr.2013.08.006 3. Msiska G, Smith P, Fawcett T. The ‘lifeworld’ of Malawian undergraduate student nurses: The challenge of learning in resource poor clinical settings. Int J Afr Nurs Sci 2014;1:35-42. https://doi.org/10.1016/j.ijans.2014.06.003 4. Missen K, McKenna L, Beauchamp A. Work readiness of nursing graduates: Current perspectives of graduate nurse program coordinators. Contemp Nurse 2015;51(1):27-38. https://doi.org/10.1080/10376178.2015.1095054 5. Hofler L, Thomas K. Transition of new graduate nurses to the workforce challenges and solutions in the changing health care environment. North Carolina Med J 2016;77(2):133-136. https://doi.org/10.18043/ncm.77.2.133 6. Komaratat S, Oumtanee A. Using a mentorship model to prepare newly-graduated nurses for competency. J Contin Educ Nurs 2009;40(10):475-480. https://doi.org/10.3928/00220124-20090923-02 7. Spector N, Blegen M, Silvestre J, et al. Transition-to-practice study in hospital settings. J Nurs Educ 2012;5(4):24-38. https://doi.org/10.1016/s2155-8256(15)30031-4 8. Greenwood J. Critique of the graduate nurse: An international perspective. Nurse Educ Today 2000;20(1):17-23. https://doi.org/10.1054/nedt.2000.0424 9. Duchscher JE. Transition shock: The initial stage of role adaptation for newly-graduated registered nurses. J Adv Nurs 2009;65(5):1103-1113. https://doi.org/10.1111/j.1365-2648.2008.04898.x 10. Rosenberg W, Donald A. Evidence based medicine: An approach to clinical problem-solving. BMJ 1995;310(6987):1122-1126. https://doi.org/10.1136/bmj.310.6987.1122 11. Voldbjerg SL, Gronkjaer M, Sorensen EE, Hall EO. Newly-graduated nurses’ use of knowledge sources: A metaethnography. J Adv Nurs 2016;72(8):1751-1765. https://doi.org/10.1111/jan.12914 12. Rich KL, Nugent KE. A United States perspective on the challenges in nursing education. Nurse Educ Today 2010;30(3):228-232. https://doi.org/10.1016/j.nedt.2009.10.015 13. Wolff AC, Pesut B, Regan S. New graduate nurse practice readiness: Perspectives on the context shaping our understanding and expectations. Nurse Educ Today 2010;30(2):187-191. https://doi.org/10.1016/j.nedt.2009.07.011 14. Monaghan T. A critical analysis of the literature and theoretical perspectives on theory and practice gap amongst newly-qualified nurses within the United Kingdom. Nurse Educ Today 2015;35(8):e1-e7. https://doi. org/10.1016/j.nedt.2015.03.006 15. Matua G, Seshan V, Akintola A, Thanka A. Strategies for providing effective feedback during preceptorship: Perspectives from an Omani Hospital. J Nurs Educ Pract 2014;4(10):24-31. https://doi.org/10.5430/jnep.v4n10p24

Accepted 14 September 2017.

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CPD questionnaire March 2018 True (A) or false (B) Adopting a role: A performance art in the practice of medicine 1. Literature suggests that the loss of empathy during training is attributed to a focus on the clinical features and treatment thereof by modern healthcare training. Medical education units: A necessity for quality assurance in health professions education in Nigeria 2. According to the 1998 Edinburgh Declaration, the main goal of any medical education programme is to deliver curative medical services. 3. One of the shortfalls of the Nigerian medical education system identified by the authors is the unreliable forms of assessment.

The perspectives of South African academics within the disciplines of health sciences regarding telehealth and its potential inclusion in student training 11. Telehealth and telemedicine are synonymous. 12. The academics’ lack of knowledge about telehealth makes it difficult for them to teach in this area.

A survey of radiation safety training among South African inter ventionalists 4. In this study, radiologists and cardiologists rated an equal level of training in radiation safety.

Comparing international and South African work-based assessment of medical interns’ practice 13. The aim of the work-based assessment (WBA) process is to ensure that doctors are performing as competent, ethical practitioners who have ‘globally connected, locally responsive attributes that are population and patient-centred’. 14. The review of the literature relating to WBA in high-income countries showed minimal focus on assessing the knowledge, skills and attitudes of interns by using a competency-based assessment framework.

Physiotherapy clinical education at a South African university 5. A 2007 review of clinical education models found that no model proved to be superior to another. 6. Work overload, time constraints and other site barriers were some of the institutional barriers identified by respondents in this study.

‘Sense of belonging’: The influence of individual factors in the learning environment of South African interns 15. Ethnicity, language and urban/rural status were identified as factors that are significantly associated with the lower perceptions of the learning environment in internship.

Creating opportunities for interprofessional, community-based education for the undergraduate dental therapy degree in the School of Health Sciences, University of KwaZulu-Natal, South Africa: Academics’ perspectives 7. Finding a common time for the students from the different disciplines to participate in interprofessional education activities was identified as the main barrier. 8. The study findings revealed that there are very few opportunities for interprofessional community-based education for dental therapy students.

The effect of undergraduate students on district health services delivery in the Western Cape Province, South Africa 16. International evidence shows that over the long term, the health service benefits of hosting students in practices and hospitals do not outweigh the demands that they place on the system.

Health education on diabetes at a South African national science festival 9. The results indicated significant gender differences in the pre- and postintervention mean percentage scores. Engagement of dietetic students and students with hearing loss: Experiences and perceptions of both groups 10. This study is the first to explore the experiences of dietetic students in providing health-promotion sessions to deaf students.

A new way of teaching an old subject: Pharmacy Law and Ethics 17. Research suggests that students involved in case-based learning (CBL) tend to be more confident in practising the skills learnt during the process. 18. A majority of the students agreed that participation in the CBL exercise helped to improve their understanding of law concepts. Transition-to-practice guidelines: Enhancing the quality of nursing education 19. Effective transition to practice has not been found to enhance socialisation and confidence among nurses. 20. As a result of the guideline development process, 11 guideline statements were formulated.

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March 2018, Vol. 10, No. 1 AJHPE