AJHPE Vol 10, No 2 (2018) by HMPG

African Journal of Health

Professions Education June 2018, 2017, Vol. 10, 9 No. No. 22

Scholarship of Africa for Africa

ISSN 2078 - 5127

AJHPE African Journal of Health Professions Education June 2018, Vol. 10, No. 2

EDITORIAL

74 Reflecting on our society? P McInerney

SHORT COMMUNICATION

EDITORIAL BOARD

EDITOR-IN-CHIEF Vanessa Burch University of Cape Town INTERNATIONAL ADVISORS Michelle McLean Bond University, QL, Australia Deborah Murdoch-Eaton Sheffield University, UK

75 Instagram: A niche for microlearning of undergraduate medical microbiology I I Osaigbovo, C F Iwegim

DEPUTY EDITORS Jose Frantz University of the Western Cape

SHORT RESEARCH REPORT

Jacqueline van Wyk University of KwaZulu-Natal

76 AIMED AT ITCHEDD: A proof-of-concept study to evaluate a mnemonic-based approach to clinical reasoning in the emergency medical care educational setting A Makkink, C Vincent-Lambert

RESEARCH

ASSOCIATE EDITORS Francois Cilliers University of Cape Town Rhena Delport University of Pretoria

79 Association between personality factors and consulting specialty of practice of doctors at an academic hospital in Bloemfontein, South Africa R van Aswegen, A Ravgee, G Connellan, C Strydom, J T Kuzhivelil, G Joubert, W J Steinberg

Patricia McInerney University of the Witwatersrand

85 Optometry students’ attitudes towards research at undergraduate level L Coetzee, S B Kruger

Anthea Rhoda University of the Western Cape

90 Factors causing stress among first-year students attending a nursing college in KwaZulu-Natal, South Africa E M Langtree, A Razak, F Haffejee 96 ‘Pain and stress are part of my profession’: Using dental practitioners’ views of occupation-related factors to inform dental training R Moodley, S Naidoo, J van Wyk 101 Occupational therapy students’ use of social media for professional practice D Naidoo, P Govender, M Stead, U Mohangi, F Zulu, M Mbele 106 Establishing consensus among inter-professional faculty on a gender-based violence curriculum in medical schools in Nigeria: A Delphi study O I Fawole, J van Wyk, A A Adejimi, O J Akinsola, O Balogun 114 Self-reported generic learning skills proficiency: Another measure of medical school preparedness V C Burch, C N T Sikakana, G D Gunston, D Murdoch-Eaton 124 Integrating critical cross-field outcomes in an anatomy course at a university of technology: A reflective perspective J D Pillay, N Govender, N Lachman 129 Strengths and challenges of community-based clinical training as viewed by academics at the University of KwaZulu-Natal, Durban, South Africa I Moodley, S Singh 136 A support programme for registered nurses in the early identification of autism spectrum disorders in primary healthcare clinics: A pilot study A-M Wium, M de Jongh

CPD questionnaire

Ntombifikile Mtshali University of KwaZulu-Natal

Michael Rowe University of the Western Cape Marietjie van Rooyen University of Pretoria Susan van Schalkwyk Stellenbosch University Elizabeth Wolvaardt University of Pretoria

HMPG

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ISSN 2078-5127

Editorial

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

Reflecting on our society? Welcome to the winter 2018 issue of AJHPE. Both the quantitative and qualitative research paradigms are represented; therefore, there is something for everyone. What struck me was how reflective of society this issue is, as it contains articles on stress, gender-based violence and use of social media. It was also interesting to note that several topics seem to be in pairs – I am sure it was not intentional! The topic of research in undergraduate curricula is addressed from two different perspectives, but both relate to students. In an undergraduate student study by Van Aswegen et al.,[1] the association between personality factors and chosen area of specialty of medical practitioners was explored. The authors identified personality types in some specialties and differences between characteristics of local specialists; these were compared with findings from other studies. In contrast, the second study that involved students sought to determine optometry students’ attitudes towards research. Coetzee and Kruger[2] report that, while students recognised several benefits to undertaking research, the time-consuming nature of conducting research and the administrative processes associated with obtaining ethical approval were viewed negatively. These findings reflect the reality of conducting research. Langtree et al.[3] report on factors contributing to stress in nursing students, whereas Moodley et al.[4] address stress in the dental profession. While the causes of stress were different in these two study cohorts, both studies recommend the inclusion of stress management programmes in undergraduate curricula. The use of social media in learning is addressed in another pair of articles. Naidoo et al.[5] found that most students in their occupational therapy sample used some form of social media and that participants were aware of the ethical dilemmas inherent in using these media. Osaigbovo and Iwegim[6] report on the use of Instagram and Facebook to complement lectures in the teaching of medical microbiology in Nigeria. Their post-intervention survey showed that engagement with material and postings were higher in Instagram. Using the Delphi technique, Fawole et al.[7] sought to obtain consensus from teachers on a gender-based violence curriculum for medical schools in Nigeria. The study identified topics for inclusion, level of study at which the curriculum should be taught, methods of teaching and who should teach. Interestingly, the written examination ranked highest as the method of assessment. Using the mnemonic AIMED AT ITCHEDD, Makkink and Vincent-Lambert[8] conducted a survey to determine teachers’ and students’ opinions on the use of the mnemonic in teaching and learning critical thinking and decision-making in patient management. The mnemonic was generally well perceived by teachers and students alike. The article by Burch et al.[9] reminded me of Paulo Freire’s[10] work, Pedagogy of the Oppressed. Freire believed that learners do not enter tertiary institutions

as blank slates. Burch et al.[9] studied the self-reported proficiency levels of medical students in six categories of generic learning skills and found a significant relationship with pre-university admission aptitude test scores, information technology proficiency on entry to university and early academic performance at university. Furthermore, academically weak students did not overestimate their skills proficiency. Pillay et al.[11] compared teaching methods used in an anatomy course with the critical cross-field outcomes specified by the South African Qualifications Authority. This form of reviewing the curriculum led to changes in teaching methods that enabled better alignment of achievement of the cross-field outcomes. I hope this brief summary of some of the contents of this issue of AJHPE piques your interest and motivates you to read this edition from cover to cover. Patricia McInerney Centre for Health Science Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa patricia.mcinerney@wits.ac.za

1. Van Aswegen R, Ravgee A, Connellan G, et al. Association between personality factors and consulting specialty of practice of doctors at an academic hospital in Bloemfontein, South Africa. Afr J Health Professions Educ 2018;10(2):79-84. https://doi.org/10.7196/AJHPE.2018.v10i2.997 2. Coetzee L, Kruger SB. Optometry students’ attitudes towards research at undergraduate level. Afr J Health Professions Educ 2018;10(2):85-89. https://doi.org/10.7196/AJHPE.2018.v10i2.728 3. Langtree EM, Razak A, Haffejee F. Factors causing stress among first-year students attending a nursing college in KwaZulu-Natal, South Africa. Afr J Health Professions Educ 2018;10(2):90-95. https://doi.org/10.7196/ AJHPE.2018.v10i2.993 4. Moodley R, Naidoo S, van Wyk J. ‘Pain and stress are part of my profession’: Using dental practitioners’ views of occupation-related factors to inform dental training. Afr J Health Professions Educ 2018;10(2):96-100. https:// doi.org/10.7196/AJHPE.2018.v10i2.1005 5. Naidoo D, Govender P, Stead M, Mohangi U, Zulu F, Mbele M. Occupational therapy students’ use of social media for professional practice. Afr J Health Professions Educ 2018;10(2):101-105. https://doi.org/10.7196/ AJHPE.2018.v10i2.980 6. Osaigbovo II, Iwegim CF. Instagram: A niche for microlearning of undergraduate medical microbiology. Afr J Health Professions Educ 2018;10(2):75. https://doi.org/10.7196/AJHPE.2018.v10i2.1057 7. Fawole OI, van Wyk J, Adejimi AA, Akinsola OJ, Balogun O. Establishing consensus among inter-professional faculty on a gender-based violence curriculum in medical schools in Nigeria: A Delphi study. Afr J Health Professions Educ 2018;10(2):106-113. https://doi.org/10.7196/AJHPE.2018.v10i2.988 8. Makkink A, Vincent-Lambert C. AIMED AT ITCHEDD: A proof-of-concept study to evaluate a mnemonicbased approach to clinical reasoning in the emergency medical care educational setting. Afr J Health Professions Educ 2018;10(2):76-78. https://doi.org/10.7196/AJHPE.2018.v10i2.543 9. Burch VC, Sikakana CNT, Gunston GD, Murdoch-Eaton D. Self-reported generic learning skills proficiency: Another measure of medical school preparedness. Afr J Health Professions Educ 2018;10(2):114-123. https://doi. org/10.7196/AJHPE.2018.v10i2.971 10. Freire P. Pedagogy of the Oppressed. London: Penguin Books, 1972. 11. Pillay JD, Govender N, Lachman N. Integrating critical cross-field outcomes in an anatomy course at a university of technology: A reflective perspective. Afr J Health Professions Educ 2018;10(2):XXX. https://doi.org/10.7196/ AJHPE.2018.v10i2.960

Afr J Health Professions Educ 2018;10(2):74. DOI:10.7196/AJHPE.2018.v10i2.1108

June 2018, Vol. 10, No. 2 AJHPE

Short Communication

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

Instagram: A niche for microlearning of undergraduate medical microbiology I I Osaigbovo,1,2 MBBS, FMCPath; C F Iwegim,2 MBBS, MHPM 1

Department of Medical Microbiology, School of Medicine, College of Medical Sciences, University of Benin, Nigeria

Department of Medical Microbiology, University of Benin Teaching Hospital, Nigeria

Corresponding author: I I Osaigbovo (zephyreternal@yahoo.com)

Context and setting

In Nigerian medical schools, lecturing is the dominant mode of delivering education during the preclinical years. The School of Medicine, University of Benin (UNIBEN), Nigeria, a first-generation institution, provided the stage for the intervention described in this report.

Why the idea was necessary

The traditional lecture is fraught with pitfalls, such as cognitive overload and low engagement between students and faculty.[1] These problems can potentially be tackled by social media.[2] Scholars in Europe and the USA have described the innovative use of social media in medical education, but little documented evidence exists to suggest that African educators are up to date with this trend. We designed and implemented an intervention to complement face-to-face lectures.

What was done

The presence and activity of students on social networking sites during their pathology year was determined using a pre-intervention survey. Facebook and the photo-sharing application, Instagram, had the most users. Respondents accessed these sites predominantly via smart phones. Content derived from the medical microbiology curriculum was posted on a dedicated Facebook page and Instagram account throughout the semester. Typical posts representing independent units of instruction consisted of an image accompanied by a concise descriptive text. A picture puzzle was also posted weekly. Students were provided with the account handles to voluntarily follow and engage on any or both social media platforms. An end-of-semester post-intervention survey was conducted.

Results and impact

There was a high level of satisfaction among participants; 91.6% agreed that the intervention enhanced learning. Specifically, posts allowed convenient, asynchronous access to content in manageable chunks (87.5%), addressed gaps in knowledge (66.7%) and afforded students opportunities to engage with their peers and facilitator (50%). Participation and engagement were higher on Instagram than Facebook (70 v.14 followers; 2 students followed both). Furthermore, 85% of respondents reported deliberately using the

platform as a mobile reference and 79.2% used it as a study tool during downtime, usually between lectures and while commuting. Accessing bite-sized content via mobile technology as and when required, whether for deliberate reference or opportunistic studying, has been described as ‘microlearning’.[3] Coincidentally, these microlearning activities were reported exclusively by Instagram users. Our take-home message from the intervention was twofold. First, the success of social media interventions is dependent on the students being positively motivated to use the selected platform. Our students possessed both Facebook and Instagram accounts, but had a greater affinity for the latter. Therefore, a thorough analysis of students’ perceptions is vital before adopting any strategy. Secondly, the outcomes suggest that Instagram is more suitable for microlearning than Facebook. We attribute this to the succinct nature of the descriptive texts and the layout of the Instagram account, which allows images to function as bookmarks for posts of interest. This intervention’s highest contribution to scholarship in medical education lies in the new questions posed: what is the impact of microlearning as a pedagogical approach?; and is Instagram a more suitable vehicle than Facebook and other social media platforms for such an approach? Our future research will be directed at providing answers. Acknowledgements. None. Author contributions. IIO was responsible for the concept, implementation, acquisition and analysis of the data, and writing of the draft. CFI was responsible for the concept, revision of the draft and intellectual content. Funding. None. Conflicts of interest. None. 1. Frederick P. The lively lecture – 8 variations. Coll Teach 1986;34(2):43-50. https://doi.org/10.1080/87567555.1 986.9926766 2. Orsini C, Evans P. Social media as a teaching strategy: Opportunities and barriers. Adv J Health Professions Educ 2015;1(1):44-46. 3. Hug T. Mobile learning as microlearning: Conceptual considerations towards enhancements of didactic thinking. Int J Mobile Blend Learn 2010;2(4):47-57. https://doi.org/10.4018/jmbl.2010100104

Accepted 16 January 2018. Afr J Health Professions Educ 2018;10(2):75. DOI:10.7196/AJHPE.2018.v10i2.1057

June 2018, Vol. 10, No. 2 AJHPE

Short Research Report

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

AIMED AT ITCHEDD: A proof-of-concept study to evaluate a mnemonic-based approach to clinical reasoning in the emergency medical care educational setting A Makkink, ND MSRV, ND EMC, BTech EMC, PDTE; C Vincent-Lambert, ND AET, NHD PSE, NHD FST, BTech EMC, MTech ED, PhD HPE Department of Emergency Medical Care, Faculty of Health Sciences, University of Johannesburg, Doornfontein Campus, South Africa Corresponding author: A Makkink (amakkink@uj.ac.za)

Background. Mnemonics are used as memory aids for teaching, learning and practice in a variety of educational contexts and domains. Mnemonics are commonly used to assist in the recall of critical components of complex or important clinical processes. The AIMED AT ITCHEDD mnemonic was designed to assist students to recall and apply steps associated with a structured clinical decision-making process. Objective. To obtain the views and opinions of a sample of educators and students regarding the perceived value of AIMED AT ITCHEDD. Method. A prospective, purposive design was followed, making use of an online questionnaire that consisted of 18 Likert-type questions, together with areas allowing for open, written comments. A total of 47 responses were received. Quantitative data from the closed questions were descriptively analysed. Thematic analysis was conducted on the narratives provided to determine emerging themes. Results. Despite concerns being raised relating to its length, AIMED AT ITCHEDD was seen as a valuable tool for clinical teaching, learning and practice by the majority of respondents. Conclusion. As a process mnemonic, AIMED AT ITCHEDD is perceived as having the potential to guide both students and practitioners with the critical thinking and decision-making processes associated with patient assessment, diagnosis and management. Further research is required to assess and quantify the extent to which the application of AIMED AT ITCHEDD improves clinical performance. Afr J Health Professions Educ 2018;10(2):76-78. DOI:10.7196/AJHPE.2018.v10i2.543

Mnemonic teaching and learning strategies have been described as syste matic procedures aimed at enhancing memory and making information more meaningful.[1] A mnemonic is an acronym created by taking the first letters of a list of words and using these to form a memorable phrase. It is thought that the use of mnemonics may develop and improve ways in which information is encoded, thereby making it easier to retrieve at a later stage.[1] Two basic types of mnemonics exist: those focused on remembering facts (fact mnemonics) and those focused on remembering rules and procedures (process mnemonics).[2] Examples of medical mnemonics include historytaking and handover mnemonics, such as AMPLE, DeMIST,[3] ASHICE,[4] SBAR[5] and CUBAN.[3] Similarly, the DISSECT mnemonic represents a classification system that has been described as easy to assimilate and a memorable method of accounting for the critically important factors that influence contemporary decision-making for the management of aortic dissection.[6] Clinical assessment and decision-making remain arguably two of the most important skills for all clinicians, and both involve complex abstract processes. This poses a challenge for health professions educators to teach and for students to master. The objective of the AIMED AT ITCHEDD mnemonic is to guide the student towards gathering, analysing, interpreting and acting on appropriate clinical information in a logical fashion.

Development of AIMED AT ITCHEDD

Development of the mnemonic followed a process of careful consideration and inclusion of the desirable characteristics of an ideal mnemonic: ease of memorisation, logical progression through steps or stages, guidance of decision-making to ensure completion of process and ease of assimilation. AIMED AT ITCHEDD requires envisaging a chief complaint as an ‘itch’

that needs to be alleviated. Interventions are therefore aimed at adequately managing the chief complaint (an itch), leading to the complaint being resolved. Hence, the itch becomes ‘itched’. The mnemonic has been designed to create novel and logical links that the student or practitioner can associate with and apply during the management of a clinical case. The AIMED AT ITCHEDD mnemonic is summarised in Table 1. The AIMED component focuses on initiating a process of clinical reasoning, which has been described as gathering and comprehending data while recalling knowledge, skills and attitudes about situations as they unfold.[7] The AT and ITCHEDD components of the mnemonic expand upon the initial phase of clinical reasoning. After analysis, information is put into a meaningful whole and applied to the new situation presented by the patient and their response to the treatment that is administered.[7] The mnemonic was introduced in the first year of the Bachelor of Health Sciences in Emergency Medical Care programme at the University of Johannes burg, South Africa, in 2014.

Method

Study design

A cross-sectional, purposive design made use of an online questionnaire to gather data. A total of 47 responses were received, comprising 26 emergency medical care educators and 21 students.

Ethical approval

Ethical approval for the study was obtained from the University of Johannesburg’s Faculty of Health Sciences Research Ethics Committee (ref. no. REC-01-125-2014).

June 2018, Vol. 10, No. 2 AJHPE

Short Research Report Table 1. Summary of the AIMED AT ITCHEDD mnemonic Letter A I M E D

Definition Assess Identify Make sure Evaluate Decide

Explanation Assess the patient and system/organ related to the chief complaint Identify the potential cause for the chief complaint Confirm your provisional diagnosis using other tests Evaluate all potential therapeutic and adverse effects of available options Decide on the most appropriate treatment and rule out contraindications

A T

Appropriate equipment Time to prepare

Ensure that you have all the appropriate equipment for the intervention Take time to prepare and set out all equipment for the intervention

I T C H E D D

Intervention performed Time to work Check result Happy or not Explore other options Decide Don’t forget

Carry out the intervention in a ‘best practice’ manner Give the intervention/treatment appropriate time to work Perform an appropriate test to determine whether or not your intervention is having the desired effect Are you satisfied that the intervention/treatment has had the desired effect? If the result is unsatisfactory, what other options are available? Decide which option is the most appropriate and start again Don’t forget to consider other potential causes or incorrect technique

Instrument

Data were collected using a purpose-compiled questionnaire that used the SoGoSurvey (SoGoSurvey Inc., USA; www.sogosurvey.com) online plat form. It consisted of 18 Likert-type, restricted-response questions. The survey also afforded respondents an opportunity to provide additional information at the conclusion of the structured question responses.

Data analysis

Quantitative data were analysed and reported descriptively. Open-ended questions were read and reread by the investigators to familarise themselves with the content. Thematic analysis formed the cornerstone of the analysis and specific attention was given to patterns and emerging themes.

Results

Educator responses

Opinions of the educators who took part in the survy were generally positive with regard to AIMED AT ITCHEDD. Almost all respondents (96%; n=25) considered a mnemonic to be a useful memory aid and indicated that a process mnemonic could be of assistance in the practical environment (92%; n=24). Most respondents (92%; n=24) considered the mnemonic logical and 62% (n=16) felt that it was easily remembered, while 84% (n=19) believed that the mnemonic was easy to learn and apply. The mnemonic was perceived as having the potential to improve the structure of task performance in both the simulated (84%; n=22) and clinical (81%; n=21) domains. The mnemonic was also perceived as having the potential to provide a foundation for adaption by the individual (92%; n=24), as well as being able to be used in the clinical environment by qualified practitioners to improve their practice (92%; n=24). Analysis of the comments from the open-ended questions indicated two main themes. The first focused on the length of the mnemonic, with a number of respondents who felt that it was quite lengthy: ‘… too many letters … .’ ‘… it is a long mnemonic … .’ We agree that AIMED AT ITCHEDD is longer than mnemonics that focus on specific components or associated steps in the patient management process. Its length reflects the difference from simple process mnemonics, as it encompasses multiple components of the entire patient management process.

June 2018, Vol. 10, No. 2 AJHPE

The second theme focused on the potential value of AIMED AT ITCHEDD. A number of respondents provided positive comments on its potential: ‘… I am keen to give this one a go … .’ ‘… the system really looks good … .’

Student responses

Similar to the educators’ responses mentioned above, those of the students were generally positive regarding AIMED AT ITCHEDD. All respondents (100%; n=21) considered a mnemonic a useful memory aid and felt that a process mnemonic could be of assistance in the practical environment (100%; n=21). The mnemonic was considered logical by most respondents (95%; n=20), 86% (n=15) felt that it was easily remembered, and 86% (n=15) believed that it was easy to learn and apply. The mnemonic was seen as having potential to improve the structure of task performance in both the simulation (100%; n=21) and clinical (95%; n=20) learning environments. It was also perceived as having the potential to provide a foundation for adaption by the individual (100%; n=21), as well as being able to be used in the clinical environment by qualified practitioners to improve their practice (100%; n=21). It was interesting that 48% (n=10) indicated that the mnemonic might be difficult to remember. Analysis of the comments from the open-ended questions heralded two themes that were identical to those of the educators’ respondents. These were its usefulness and length, and included: ‘… very helpful and logical but somewhat long … .’ ‘… this mnemonic is a great tool [to assist me] in a simulation assessment … .’ ‘… the mnemonic has helped me develop my own structure … .’

Discussion

Many of the respondents in this study felt that mnemonics were useful aids within the clinical practice domain. As a process mnemonic, AIMED AT ITCHEDD was seen as having the potential to guide both student and practitioner through critical thinking and decision-making processes associated with patient assessment, diagnosis and management. AIMED AT ITCHEDD was acknowledged as being valuable and useful in guiding students through the critical thinking and decision-making processes. However, it was perceived as being relatively lengthy. The length of a mnemonic is often indicative of the complexity of the processes that

Short Research Report it aims to guide. Some mnemonics advocated in other domains are also considered lengthy; examples include FASTHUG-MAIDENS[8] and A-AB-B-C-C-D-D-E-E.[9] We argue that AIMED AT ITCHEDD, although perceived as lengthy, is comprised of three words – each representing a ‘bite-sized chunk’. We concede that there remain a number of factors that have the potential to influence clinical decision-making. These include the individual’s previous experiences, problem-solving, critical thinking and clinical reasoning abilities.[7] The intention is that the maturing practitioner will not robotically follow AIMED AT ITCHEDD ad infinitum, but will over time adapt the mnemonic to best suit their own context and practice.

Study limitations and future research

The online survey evinced 47 responses from the emergency medical care domain, and as such the generalisability of these results and findings to the wider health science educator and population cannot be determined. The importance of clinical reasoning in the healthcare education sphere must not be under-emphasised. It is important to ascertain whether this method has the potential to develop critical thinking across other healthcare disciplines. The questionnaire did not assess whether use of AIMED AT ITCHEDD improved performance during simulated or actual patient assessment and management. This remains an area for future research, where the effectiveness of the mnemonic can be tested.

Acknowledgements. None. Author contributions. AM conceptualised the mnemonic. AM and CV-L designed the study and managed the data collection, analysis and write-up. Funding. None. Conflicts of interest. None.

1. Bakken JP, Simpson CG. Mnemonic strategies: Success for the young-adult learner. J Hum Resour Adult Learn 2011;7(2):79-85. 2. Manalo E. Uses of mnemonics in educational settings: A brief review of selected research. Psychologia 2002;45:69-79. https://doi.org/10.2117/psysoc.2002.69 3. Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Clinical handover of patients arriving by ambulance to the emergency department – a literature review. Int Emerg Nurs 2010;18(4):210-220. https://doi.org/10.1016/j. ienj.2009.11.006 4. Budd HR, Almond LM, Porter K. A survey of trauma alert criteria and handover practice in England and Wales. Emerg Med J 2007;24(4):302-304. https://doi.org/10.1136/emj.2006.038323 5. Randmaa M, Mårtensson G, Leo Swenne C, Engström M. SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: A prospective intervention study. BMJ Open 2014;4:e004268. https://doi.org/10.1136/bmjopen-2013-004268 6. Dake MD, Thompson M, van Sambeek M, Vermassen F, Morales J. A new mnemonic-based approach to the categorization of aortic dissection. Eur J Vasc Endovasc Surg 2013;46(2):175-190. https://doi.org/10.1016/j. ejvs.2013.04.029 7. Ackermann A, Gore T, Hewett B, et al. Standards of best practice: Simulation. Clin Simul Nurs 2013;9(Suppl 6):S3S11. https://doi.org/10.1016/j.ecns.2013.05.008 8. Masson SC, Mabasa VH, Malyuk DL, Perrott JL. Validity evidence for FASTHUG-MAIDENS, a mnemonic for identifying drug-related problems in the intensive care unit. Can J Hosp Pharm 2013;66(3):157-162. https://doi. org/10.4212/cjhp.v66i3.1252 9. Baugher KM, Mattu A. Ten rules to assess and manage the acutely deteriorating patient: A practical mnemonic. Patient Saf Surg 2011;5(1):29. https://doi.org/10.1186/1754-9493-5-29

Accepted 23 October 2017.

June 2018, Vol. 10, No. 2 AJHPE

Research

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

Association between personality factors and consulting specialty of practice of doctors at an academic hospital in Bloemfontein, South Africa R van Aswegen,1 Undergraduate medical student; A Ravgee,1 Undergraduate medical student; G Connellan,1 Undergraduate medical student; C Strydom,1 Undergraduate medical student; J T Kuzhivelil,1 Undergraduate medical student; G Joubert,2 BA, MSc; W J Steinberg,3 MB BCh, DTM&H, DPH, Dipl Obst (SA), MFamMed, FCFP (SA) School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa 3 Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa 1 2

Corresponding author: W J Steinberg (steinbergwj@ufs.ac.za)

Background. Studies found an association between personality types and field of specialty. The current study could assist aspiring specialists in deciding which specialty they are best suited for by comparing their own personalities with the results. Objectives. To explore the personality characteristics of doctors in three consulting and four surgical specialties at an academic hospital in Bloemfontein, South Africa. Methods. In this analytical cross-sectional study, questionnaires, including the Zuckerman-Kuhlman Personality Questionnaire, were handed out. Overall, 58 consultants and senior registrars from the departments of Family Medicine, Paediatrics and Internal Medicine (response rate 71.6%) and 70 consult ants and senior registrars from surgical specialties (response rate 60.3%) participated. Results. Family medicine had the lowest median score for impulsive sensation seeking (21.1%) and aggression-hostility (11.8%), and highest for parties and friends (33.3%). Paediatrics scored highest for neuroticism-anxiety (44.7%) and aggression-hostility (23.5%). Internal medicine scored highest for sociability (25.0%) and isolation intolerance (37.8%), and lowest for neuroticism-anxiety (36.8%) and activity (47.1%). Overall, the consulting group scored lower than the surgical group for impulsive sensation seeking, aggression-hostility, sociability and activity, and higher for neuroticism-anxiety. Conclusion. The study identified personality types of some specialties, and revealed differences between characteristics of local specialists compared with findings from studies elsewhere. Afr J Health Professions Educ 2018;10(2):79-84. DOI:10.7196/AJHPE.2018.v10i2.997

The concept of personality as a measurable trait is hindered by the lack of consensus in the field of psychology on the appropriate model of personality. Personality psychologists have attempted to attach biological functions to traits and the diversity of traits, and proposed numerous models.[1,2] The alternative five factorial model of personality claims that human personality can be explained by five broad factors[3] that have a strong biologicalevolutionary basis.[4] These five factors are:[3] • Impulsive sensation seeking: ‘The tendency to act quickly on impulse without planning, often in response to a need for thrills and excitement, change and novelty.’ • Neuroticism-anxiety: ‘The tendency to be tense and worry, overly sensitive to criticism, easily upset, and obsessively indecisive.’ • Aggression-hostility: ‘The tendency to express verbal aggression and show rudeness, thoughtlessness, vengefulness, spitefulness, a quick temper and impatient behaviour.’ • Sociability: ‘Tendencies to interact with others, enjoyment in being with others, and intolerance for social isolation.’ • Activity: ‘The tendency to be active, to prefer challenging work, and being impatient or restless when there is nothing to do.’

Numerous studies have attempted to classify under- and postgraduate medical students and specialists into personality categories.[4-10] A study[5] published in 2004 used the Cloninger Inventory to identify the influence of temperament on medical students’ choice of specialty. They distributed the questionnaire to 682 medical students with a choice of preference from procedure-orientated specialties (surgery, obstetrics and gynaecology) and primary care specialties (family medicine, internal medicine, paediatrics). Procedure-orientated specialties had higher novelty-seeking scores and scored high on co-operativeness and self-directedness. Those interested in emergency medicine scored high on novelty-seeking and low on harmavoidance scales, similar to surgeons, but higher in reward dependence than surgeons. Students choosing primary care specialties, especially paediatrics, had the highest reward-dependence scores. Those choosing internal medicine had higher harm-avoidance scores than those choosing surgery and emergency medicine. Hojat and Zuckerman[3] tested the personalities of 1 076 medical students at Jefferson Medical College, Philadelphia, USA, between 2002 and 2006, according to specialty interest. The study used the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) measuring the five personality factors

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Research mentioned above. It showed that those interested in surgical specialties had higher than average scores for impulsive sensation-seeking and aggressionhostility factors, and lower scores in the neuroticism-anxiety scale. Those interested in obstetrics and gynaecology were more often females and scored highest in neuroticism-anxiety. Those interested in hospital care scored lower on the sociability scale, while those interested in emergency medicine and surgery had high activity scores, especially compared with psychiatry students. Many doctors and medical students are faced with the dilemma of whether to specialise. To specialise in a field of medicine is often a lifelong commitment – one that requires careful consideration. We believe that perceptions of the type of personalities of individuals in a specific specialty may influence the choice of specialty, and many of these perceptions may be based on stereotypes. The current study could assist aspiring specialists in deciding which specialty they are best suited for by comparing their own personalities with the results.

Objectives

The aim of the study was to explore any association between the personality factors and consulting specialty of practice of doctors at an academic hospital in South Africa (SA) in 2014. Furthermore, to provide a broader context, the overall results for consulting and surgical groups are provided.

Methods

Design and setting

This was an analytical cross-sectional study conducted over 4 months, from August to November 2014, at an academic hospital in Bloemfontein, SA.

Population and sampling strategy

The target population consisted of 197 doctors working as senior registrars or consultants at 7 specialty departments at the academic hospital. The specialties were assigned to the ‘consulting group’ (family medicine, internal medicine and paediatrics) or the ‘surgical group’ (anaesthesiology, obstetrics and gynaecology, orthopaedic surgery and surgery). This article focuses mainly on the consulting group, which consisted of 81 doctors.

Inclusion criteria

Senior registrars (in their third or fourth year of the MMed degree) and specialist consultants, of all ages, who practised at the academic hospital were included. There were no exclusion criteria.

Method of sample selection

Convenience sampling of all consultants and senior registrars present at departmental meetings was performed, unless they declined. Completed questionnaires were retrieved at the meeting or from the departmental secretary if these were not completed at the meeting.

Data collection

The psychometric tool used in this study was the ZKPQ.[11] It measures five factors of personality: (i) impulsive sensation seeking; (ii) neuroticismanxiety; (iii) aggression-hostility; (iv) sociability; and (v) activity. Impulsive sensation seeking is subdivided into impulsivity and sensation seeking. Sociability is subdivided into parties and friends, and isolation intolerance, and activity is subdivided into work effort and general activity.

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The ZKPQ, a valid self-report measure,[12] consists of 99 items in true/ false format. In addition to the ZKPQ, a section was added to the study questionnaire to capture demographic data such as age, gender and years in field of specialty. The questionnaire was available only in English.

Pilot study

Eight medical interns training at the academic hospital were included in the pilot study. A few minor adjustments were made to the questionnaire. The data collected were not included in the study.

Data analysis

Data were analysed by the Department of Biostatistics, Faculty of Health Sciences, University of the Free State (UFS), Bloemfontein. Results are presented as median percentages of the maximum result for each specific scale because of skew data distributions. For each scale, the score obtained was expressed as a percentage of the maximum total score applicable for that scale. If >20% of the questions for a specific scale were not answered, the participant’s result for that scale was excluded from the results. The ZKPQ includes a sixth scale, i.e. infrequency, which identifies participants who provide invalid test results by selecting responses that are unlikely to be true.[3] A comparison was made between results that excluded questionnaires with scores >30% on the infrequency scale and results that did not exclude questionnaires with scores >30%. A few differences were noted, but these were not significant enough to warrant the use of the results that excluded questionnaires. Statistical analysis was performed using the non-parametric MannWhitney test, and 95% confidence intervals (CIs) for the median differences were calculated. Values p<0.05 were considered statistically significant.

Ethical approval

The protocol was approved by the Ethics Committee of the Faculty of Health Sciences, UFS (ref. no. STUD no 28/2014). Permission to conduct the study was obtained from the heads of the academic departments, as well as from the head of clinical services at the academic hospital. Permission to use the ZKPQ in the study was given via email by Prof. Marvin Zuckerman (co-creator), along with the manual that was used to score each individual’s results.

Results

The response rates from each consulting specialty and the overall consulting and surgical groups are shown in Table 1. Family medicine was the consulting specialty with the highest median age (54 years) and duration of practice (14.5 years) (Table 2). All consulting specialties had higher medians than the surgical group (age: p<0.01; Table 1. Sample and population sizes Specialty Family medicine Internal medicine Paediatrics Consulting group, all Surgical group, all

Sample size, n 13 25 20 58 70

Population size, n 16 37 28 81 116

Response rate, % 81.3 67.6 71.4 71.6 60.3

Research 95% CI 2 - 10 years; duration of practice: p<0.01; 95% CI 1 - 6 years). All consulting specialties had a larger percentage of females than the surgical specialties (p=0.03).

Impulsive sensation seeking

Family medicine had the lowest median score (21.1%) for impulsive sensation seeking (Fig. 1). All three consulting specialties had medians of 36.4% for the subscale sensation seeking. Family medicine and paediatrics both had medians of 0 for the subscale impulsivity. All three consulting specialties had lower medians than the overall surgical group for impulsive sensation seeking (p<0.01; 95% CI ˗25.8%; ˗5.3%) and the subscale sensation seeking (p=0.01; 95% CI ˗27.3%; ˗3.6%). The subscale sensation seeking scored higher than impulsivity across consulting and surgical groups.

Neuroticism-anxiety

Paediatrics scored the highest (44.7%) and internal medicine the lowest (36.8%) for neuroticism-anxiety. The consulting group scored higher than the surgical group (p=0.06; 95% CI 0; 15.8%) (Fig. 2).

Aggression-hostility

Paediatrics scored the highest (23.5%) and family medicine the lowest (11.8%) for aggression-hostility (Fig. 3). There was a strong distinction between the two major groups, with the consulting group scoring much lower than the surgical group (p<0.01; 95% CI 11.8%; 23.5%).

Sociability

Internal medicine had the highest score for sociability (25.0%) and the subscale isolation intolerance (37.8%) (Fig. 4). Family medicine scored the highest for the

Table 2. Demographic data of specialties Demographic data Median age, years Range, years Median duration of practice, years Range, years Gender* Male, n (%) Female, n (%) Ratio

Family medicine 54.0 32 - 65 14.5 4 - 32

Internal medicine 36.5 29 - 64 8.0 2 - 30

Paediatrics 40.5 30 - 63 9.5 1 - 30

Consulting, all 42.0 29 - 65 10.0 1 - 32

Surgical, all 35.0 28 - 78 4.0 1 - 50

9 (69.2) 4 (30.8) 2.25:1

12 (50.0) 12 (50.0) 1:1

9 (56.3) 7 (43.7) 1.3:1

30 (56.6) 23 (43.4) 1.3:1

49 (75.4) 16 (24.6) 3.1:1

*Gender missing: internal medicine (n=1); paediatrics (n=4); consulting, all (n=5); surgical, all (n=5).

Impulsive sensation seeking (main) Sensation seeking (subscale) Impulsivity (subscale) 45.5

36.4

36.8

36.4

Score, %

21.1

ine

12.5

10 0

ine

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26.3

29.0

26.3

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44.7

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Specialty

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Specialty Fig. 1. Median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor impulsive sensation seeking.

Fig. 2. Median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor neuroticism-anxiety.

subscale parties and friends (33.3%). The consulting group scored lower than the surgical group for sociability (p=0.01; 95% CI ˗11.8%; 0).

Activity

Internal medicine scored the lowest on the scale for activity (47.1%), as well as for the subscale general activity (33.3%) (Fig. 5). Paediatrics had

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Research

Activity (main) General activity (subscale) Work effort (subscale)

50 40.6

Score, %

30 23.5

17.7

60 Score, %

10 0

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Sociability (main) Parties and friends (subscale) Isolation intolerance (subscale)

37.8

37.5

Score, %

33.3

25.0

20 11.1

25.0

23.5

17.7

22.2

16.7

11.1

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Specialty Fig. 4. Median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor sociability.

the highest score for the subscale work effort (68.8%). The consulting group scored significantly lower than the surgical group for activity (p<0.01; 95% CI ˗17.6%; ˗5.9%), as well as for the subscales general activity (p=0.06) and work effort (p=0.01).

Discussion

This study was conducted among specialist doctors working at an academic hospital in Bloemfontein. They are therefore either in an academic position or pursuing academic studies. To evaluate a more homogenous group, it was decided that only doctors in the academic setting would be included. Doctors drawn to academics may have a different personality type with different aims in life, compared with doctors in private practice.

55.6

66.7

54.6 55.6

50.0

47.1

33.3

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Fam

ine

dic

e ly m

ine

dic

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ern Int

rics

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l l, a

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iat

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Specialty

Fig. 5. Median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor activity.

Family medicine

29.4

30 25.0

62.5

61.8 61.1

Fig 3. Median scores of the different specialties of the consulting group, as well as the overall consulting group and the overall surgical group for the factor aggression-hostility.

62.5

Specialty

23.5

64.7

17.7

11.8

ly mi

75.0 70.6

68.8

Family medicine scored the lowest for the factor aggression-hostility. A possible explanation could be the higher median age of this group, causing aggression and hostility to decrease with increasing maturity and experience, while the patient-orientated nature of the practice necessitates non-aggressive behaviour. Family medicine also had the lowest impulsive sensation-seeking scores. The results suggest that family medicine specialists are in general not risktaking or novelty-seeking individuals. This may again be owing to the higher median age, or the broader scope of the specialty, making it less exciting to the more adrenaline-driven individuals. However, one would expect that a specialty with a broad scope would allow for greater diversity, which is an archetypical need for impulsive and sensation-seeking individuals. Impulsivity was very low across all the specialties. This may be because of high expectations of professional conduct and intolerance to impulsivity in the work environment of medical specialists. Sociability is ‘the tendency to interact with others, enjoyment in being with others, and apparent intolerance for social isolation’. Although sociability may not be a crucial aspect of an effective doctor’s personality, proficiency in interpersonal and communication skills is highly regarded by patients, according to a study on patient perspectives on physician behaviour.[13] For the sociability scale, family medicine had the lowest score for isolation intolerance (25.0%) and the highest for parties and friends (33.3%). The reverse is true for the other two specialties. It appears, therefore, that family medicine specialists may not so much be asocial as being highly tolerant of social isolation. An example of a statement from the ZKPQ for work effort is: ‘I like a challenging task much more than a routine one’, and for general activity: ‘I like to be doing things all of the time.’ Although family medicine scored lowest of all specialties in the subscale work effort (50.0%), it scored highest

Research in the activity (64.7%) scale. This may indicate that these specialists prefer being busy with multiple activities than focusing on a single challenging task.

Internal medicine

Internal medicine recorded scores with the widest difference between two subscales: work effort (62.5%) and general activity (33.3%). This could reflect a penchant for hard and challenging work, but not a busy lifestyle. Internal medicine also had the lowest score of the consulting specialties for neuroticism-anxiety and the highest score for sociability, although only marginally in both scales. Under isolation intolerance, internal medicine had a higher score than the overall score for consulting and surgical groups.

Paediatrics

The highest score for neuroticism-anxiety was observed in this specialty. The researchers hypothesise that paediatricians’ preference for caring for and interacting with children may correspond with greater sensitivity and anxiety. In other words, the specialty draws more sensitive and concerned individuals who tend to be more anxious themselves. Hojat and Zuckerman[3] showed that there was a greater need in childcare for ‘harm avoidance’, a trait that they found to correlate with high neuroticism and anxiety. Paediatrics scored the lowest in sociability. This was surprising, as the authors believed that interaction with children would be associated with a sociable disposition. An aversion to social pressure may be associated with high neuroticism-anxiety, low sociability and a preference for interacting with children and mothers. Furthermore, social interaction with children is different from interacting with peers. It may be that the lack of ‘typical’ socialising with patients causes a decrease in sociability over time. Even though paediatrics had low aggression-hostility scores (23.5%), these were still higher than those of the other two consulting specialties. This was surprising, as it was assumed that people who interact with children would be the least aggressive.

Consulting group v. surgical group

The surgical group was found to have higher impulsive sensation-seeking scores than the consulting group. This may be attributed to the physically stimulating nature of surgical procedures that attracts ‘novelty-seeking’ individuals. The consulting group had higher neuroticism-anxiety, which may be due to differences in the doctor-patient relationship. The consulting group was much less aggressive. This may also be attributed to a difference in patient interaction, with consulting specialists needing to be approachable, as their work is centred on consultations, not procedures. The consulting group had a lower sociability score than the surgical group. One explanation for this is the higher neuroticism-anxiety of this group, which implies more sensitivity to criticism. Moreover, the need for teamwork during surgical procedures, greater academic emphasis of consulting specialties, higher median age of consulting specialists (42 v. 35 years), and difference in role models may have played a part. The ZKPQ study[3] among medical students found that sociability correlated positively with aggression-hostility. However, it was expected that these two factors would be inversely related to each other. Rudeness, impatient behaviour and a quick temper would not normally be associated with good interpersonal

relationships. It may be that a limited amount of aggression-hostility could be perceived as social ‘dominance’, and therefore greater success in socialising with others. The ZKPQ study[3] showed no statistically significant difference in sociability between the medical student groups tested. A study of 590 medical students in Saudi Arabia,[14] using the ZKPQ, found that those interested in surgical specialties scored higher than all other specialty choice groups on all factors, including neuroticism-anxiety, except for activity.

Study limitations

The small population and sample sizes for each specialty made generalisation and comparison difficult, and prevented more in-depth analysis into the influence of gender, age and years in field of specialty on personality factors. The study only comprised doctors at an academic hospital, and may not fully reflect the personality types of doctors working in the greater private and public sectors. Sampling bias was also of concern, as the completion of the questionnaires depended on the availability of doctors. Gender and age were measured, but due to limited sample size, it was not possible to correct for these biases. Recruiting of participants at meetings may have systematically excluded doctors with specific personalities, who do not attend meetings. The ZKPQ does not exhaust the entire range of personality characteristics that any person can possess, and it is emphasised that the results merely provide indications and suggestions and should not be used to place any individuals into ‘boxes’. However, all the specialties had a great range in the minimum and maximum values, demonstrating that specialties are not exclusive of any personality types, but that there may be specialties that are more suited to a person’s personality than others. Although published research generally agrees regarding the grouping of family medicine, internal medicine and paediatrics specialties as primary care/people-orientated/consulting, comparison with other studies are hampered by some differences in categorisation of specialties, e.g. Meh mood et al.[14] grouped anaesthesiology with hospital-based procedures, whereas we grouped it with surgical specialties.

Conclusion

The study helped to characterise the personalities of doctors in some specialties, as demonstrated in Bloemfontein, and revealed some of the differences between findings regarding local specialists and results from studies elsewhere.

Recommendations

Potential future research efforts that we recommend include: (i) a comparison of personality factors, such as sociability for different professions; (ii) a study comparing the personalities of consulting specialists with correction for gender; and (iii) a study on the level of neuroticism-anxiety of South Africans in general. It could not be confidently ascertained whether choice of specialty was a product of personality, or whether personality was a product of specialty. A study on whether conforming to the personality norm of one’s profession has an impact on career satisfaction will substantiate research on personalities and professions. It is known that certain personality traits impact on career satisfaction,[15-17] but it is not known whether conforming to the norm is related to career satisfaction.

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Research Acknowledgements. The researchers would like to acknowledge the following people for their assistance, guidance and suggestions: Dr Chris Snowdowne, the initial study leader, who formulated the idea for the study and guided the researchers throughout the planning phase; Prof. Marvin Zuckerman, from the University of Delaware, USA, for generously providing the ZKPQ free of charge for use in the study; Mr Jacques le Roux, a colleague of the researchers, for suggesting the recommendation of investigating whether matching the personality norm of one’s field is associated with career satisfaction; the Research Committee of the School of Medicine, UFS, for providing funding for printing; and Ms T Mulder, medical editor, School of Medicine, UFS, for technical and editorial preparation of the manuscript. Author contributions. RvA, AR, GC, CS and JTK developed the protocol, designed the questionnaire, performed the data collection and coding of questionnaires and wrote a draft report as part of an undergraduate research module. WJS was the supervisor of this study, contributing to the planning, interpretation of results and writing of the manuscript. GJ assisted with the planning of the project, performed the analysis of the data, and assisted with the interpretation of the data and the writing of the manuscript. Funding. None. Conflicts of interest. None. 1. Hall CS, Lindzey G. Theories of Personality. New York: John Wiley, 1957. 2. Lewin K. A Dynamic Theory of Personality. New York: McGraw-Hill, 1935.

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3. Hojat M, Zuckerman M. Personality and specialty interest in medical students. Med Teach 2008;30(4):400-406. https://doi.org/10.1080/01421590802043835 4. Zuckerman M. Zuckerman-Kuhlman Personality Questionnaire. In: De Raad B, Perugini M, eds. Big Five Assessment (ZKPQ), and Alternative Five-Factorial Model. Seattle: Hogrefe & Huber, 2002:377-396. 5. Vaidya NA, Sierles FS, Raida MD, Fakhoury FJ, Przybeck TR, Cloninger CR. Relationship between specialty choice and medical student temperament and character assessed with Cloninger inventory. Teach Learn Med 2004;16(2):150-156. https://doi.org/10.1207/s15328015tlm1602_6 6. Rathi AA, Prabhugaonkar SV, Jadhav BS, Shanker S, Dhavale HE. Study of personality factors in postgraduate medical students. Bombay Hosp J 2008;50(2):245-249. 7. Freeman B. The Ultimate Guide to Choosing a Medical Specialty. 3rd ed. New York: McGraw-Hill Medical, 2012. 8. Coombs RH, Fawzy FI, Daniels ML. Surgeons’ specialities: The influence of medical school. Med Educ 1993;27(4):337-343. 9. Zimet CN, Held ML. The development of views of specialties during four years of medical school. J Med Educ 1975;50(2):156-166. 10. Linn BS, Zeppa R. Does surgery attract students who are more resistant to stress? Ann Surg 1984;200(5):638-643. https://doi.org/10.1097/00000658-198411000-00014 11. Zuckerman M, Kuhlman MD, Thornquist M, Kiers H. Five (or three) robust questionnaire scale factors of personality without culture. Personal Individ Diff 1991;12(9):929-941. https://doi.org/10.1016/0191-8869(91) 90182-B 12. Gomà-i-Freixanet M, Wismeijer AA, Valero S. Consensual validity parameters of the Zuckerman-Kuhlman personality questionnaire: Evidence from self-reports and spouse reports. J Personal Assess 2005;84(3):279-286. https://doi.org/10.1207/s15327752jpa8403_07 13. Bendapudi NM, Berry LL, Frey KA, Parish JT, Rayburn WL. Patients’ perspectives on ideal physician behaviors. Mayo Clin Proc 2006;81(3):338-344. https://doi.org/10.4065/81.3.338 14. Mehmood SI, Khan MA, Walsh KM, Borleffs JC. Personality types and specialist choices in medical students. Med Teach 2012;35(1):63-68. https://doi.org/10.3109/0142159X.2012.731104 15. Lounsbury JW, Loveland JM, Sundstrom ED, Gibson LW, Drost AW, Hamrick FL. An investigation of personality traits in relation to career satisfaction. J Career Assess 2003;11(3):287-307. https://doi.org/10.1177/ 1069072703254501 16. Levy JJ, Richardson JD, Lounsbury JW, Stewart D, Gibson LW, Drost AW. Personality traits and career satisfaction of accounting professionals. Individ Diff Res 2011;9(4):238-249. 17. Judge TA, Heller D, Mount MK. Five-factor model of personality and job satisfaction: A meta-analysis. J Appl Psychol 2002;87(3):530-541. https://doi.org/10.1037/0021-9010.87.3.530

Accepted 9 November 2017.

Research

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

Optometry students’ attitudes towards research at undergraduate level L Coetzee,1 MHPE; S B Kruger,2 PhD, HPE 1 2

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

Corresponding author: L Coetzee (coetzeels@ufs.ac.za)

Background. Universities worldwide are required to increase their levels of research productivity. Objective. To bring about positive changes in research perspectives if the factors contributing to the attitude of undergraduate optometry students can be identified, enhanced and rectified. Methods. Three nominal group technique (NGT) discussions were conducted with 22 final-year (4th-year) optometry students in central South Africa (SA) to reach consensus on the most important factors that students regarded as influencing their undergraduate research experiences. Data gathering and analysis took place simultaneously, while participants prioritised the data. Data were analysed by in vivo coding, and categories were grouped according to themes that emerged from the codes. Results. Ranking and content analysis of coded statements yielded positive and negative categories, as well as categories with mixed codes. The major factor influencing students’ attitudes towards research was administration and the time-consuming nature of their research projects. Recommendations for more effective administration are given. Conclusions. It was concluded that active steps should be taken by the Department of Optometry, University of the Free State, Bloemfontein, SA, to alter and minimise negative aspects encountered by the students, which could assist future students’ experiences of research at undergraduate level. Afr J Health Professions Educ 2018;10(2):85-89. DOI:10.7196/AJHPE.2018.v10i2.728

During the past decade, increasing pressure has been placed on universities to emphasise research outputs, as it is acknowledged that higher education and the resultant research innovation accomplishments are strategically interwoven.[1] Through research findings, resources can be utilised more effectively and solutions for local health-based problems can be implemented. Optometry is a primary healthcare profession and often the first point of contact for many patients. The use of best practice through evidence-based medicine is a trend in many higher education departments.[2] This is equally true for departments of optometry at institutions of higher education in South Africa (SA). By identifying factors that contribute towards undergraduate students’ attitudes to research, it is argued that a more positive attitude can be developed if positive factors are enhanced and negative factors are rectified. The resultant research may then lead to the advancement of optometric knowledge that could translate into better-skilled practitioners, who may consequently implement better patient care. Patient care is a focus point of the intended implementation of the National Health Insurance (NHI) in SA. This will result in an increase in the number of optometrists trained, with the ability to use the latest patient care procedures. There is therefore a need for optometric education to evolve through research and evidence-based healthcare methodologies. Consequently, a strong research culture in departments of optometry is imperative. There is limited information on optometry students’ attitudes towards research. Despite similar studies having been undertaken with medical, nursing, chiropractic and social work students in SA,[2-4] this is the first SA study to address the knowledge gap of optometry students. Students are the future of the profession, and inculcation of a research culture in these students could promote lifelong learning.

Krech and Crutchfield[5] emphasise the importance of knowing the beliefs and attitudes of people, as it is possible to predict and influence their behaviour. Also, by identifying the attitude towards research, findings can influence how educators teach research, as attitudes cannot be directly observed but can be inferred from individuals’ self-reports and behaviour.[6]

Attitude theory

Historically, the most prominent of the attitude theories has been the tripartite approach, which encompasses emotion, cognition and behaviour. Cognitive origins[7] encompass processes such as a person developing positive or negative connotations about an object through gaining knowledge. Attitudes may also be formed from the emotional reactions are experienced when exposed to an object. In this model, attitude is manifested as beliefs, feelings and actions.[8] The cognitive aspect relates to students needing to know and understand the possibilities of conducting research and its use. The affective aspect is equally important, as students need to feel optimistic about and enjoy doing research. The behavioural aspect refers to students attempting to carry out or plan to learn more about research. With these three aspects as the theoretical foundation, the objective of the study was to identify the factors contributing to final-year students’ attitudes towards research in the Department of Optometry, University of the Free State, Bloemfontein, SA.

Methods

Nominal group technique (NGT) discussion sessions were held with students under the supervision of an experienced facilitator. In this study, as per the NGT process, data gathering and analysis took place simultaneously while the participants prioritised the data.[8] The researcher (LC) used Van

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Research Breda’s[8] guidelines, which recommend a method to analyse multiple NGT sessions and combine the results of these sessions as outlined below. Van Breda’s guidelines are well accepted in SA, and follow a step-by-step process, creating clear instructions for repeatability.

Step 1

The facilitator welcomed all the participants. The question was posed to the group, and the facilitator provided brief information about the topic.

Step 2

The participants spent a few minutes writing down their views on the topic or question, and were encouraged to note as many ideas as possible. This was done in silence and had a time limit of 10 minutes.

Step 3

Each participant in turn contributed an idea, which the facilitator recorded on the flip chart. Similar suggestions were grouped together where appropriate. Partici pants were allowed to skip a turn and then take part again during a later round.

Step 4

The group discussed each of the contributions for clarification. None of the ideas was allowed to be omitted. The discussion proceeded with one item at a time and one person speaking at a time.

Step 5

Participants ranked the ideas by voting for five statements, prioritising their opinions. Students prioritised the different statements they recorded during the NGT interviews by identifying and scoring the five most important ones, giving a value of 5 to the most important statement and a value of 1 to the statement they regarded as the least important. The votes were summated to obtain the five most important statements. The statement that received the highest score was then ranked number 1, continuing in this way. Consensus was reached in this manner. When combining the topmost five positive statements from the three groups, the statements mostly related to knowledge gain, the process of research, communicating research results or findings to participants, and aspects of organising and planning the research project. These responses were grouped according to the similarity of the context of the statements. Each of the statements from the three groups was given a stand-alone code. These codes were then grouped according to their similarity to form a theme. The categories were identified in this way. This technique gives all participants a chance to voice their opinions. The participants are viewed as experts, as they are expert on how they perceive their experiences. Harvey and Holmes[9] confirmed the NGT as a reliable method to determine priorities and considered it valid and effective for problem identification.

Sampling

All final-year students were invited to participate. The researcher holds a relativist view and acknowledges that each student might have a different experience of the exposure to research in the Department of Optometry, and might interpret it in a personal manner, which could influence their attitude towards research. For these reasons, the sample size was viewed as sufficient.

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Purposeful sampling was used to recruit 22 of the 23 registered final-year (4th-year) optometry students, who were in the process of completing a research project in 2014. Informed consent was obtained through distributing information leaflets regarding the study. Participants had the right to withdraw before they signed letters of consent.

Data collection

Broad questions, typically used in the NGT, were formulated. The questions were constructed to probe any research-related experience of a student. The facilitator took a few minutes before each session to ensure that the students understood the scope of the questions. These were piloted at the first nominal group session to ensure that there was no ambivalence regarding the questions. Three nominal group sessions were completed (n=8, n=6, n=7). The questions, which were not altered, were as follows: • What are the positive experiences related to research? • What are the negative experiences related to research? As the participating students were required to continue adding statements until all opinions or experiences were listed, completeness/saturation of the data was achieved. This study also used descriptive coding, which provides the substance of the data, in vivo coding that uses verbatim statements, as well as emotion coding.

Results

Of the 22 final-year optometry students who participated in the study, the majority were female (n=19; 86.4%), and the mean age of this group was 22 (range 21 - 31) years. Among the positive statement categories, the following emerged: benefits of research, research process, reflection, group work, gaining information, skills development, participants, supervision and emotion. Statements centred mostly on skill gains; the participants felt they had improved their communication and time management skills, as well as learning to plan and organise themselves. The statements in Table 1 are the verbatim responses that were recorded from the three groups (indicated by i, ii and iii). The prioritisation is also reflected (1 for the most important), and if one statement received the same number of votes, the numbering was indicated as 4a, 4b, etc. The negative statements (Table 2) related mostly to the time-consuming nature of conducting research, administrative guidelines or processes in the different departments, resources and the research process itself, emotions elicited and level of satisfaction (or dissatisfaction) with regard to their experiences. Students were aware of the overall emotional and exertional input, and that the return on their investment was negative. A unique finding was the time-consuming nature of obtaining permission from various offices to gain ethical clearance. Different ethical procedures are required when using patients, students or individuals from the public in research projects. With the tripartite model of attitude as a reference point, Fig. 1 indicates how each of the categories compiled from the data aligns with one or more of the components of this seminal model of attitude. The overlap of some categories emphasises the complex nature of attitude. These combined valences show that within the affective domain, should the resources in the Department of Optometry improve, the overwhelming feeling of the students would be more positive.

Research Table 1. The five topmost positive statements from the three nominal group technique groups with regard to their experiences of research Category Benefits of research/ reflection/research process Gaining information

Group work Participants/skills development Research process/skills development Research process Skills development/resources Skills development

Skills development/participants Supervision Emotions

Affective or emotive • Emotions • Reflection • Time-related factors • Resources

Behavioural • Skills development • Group work • Participants • Supervision • Reflection • Emotions

Statement Gaining more information that could possibly help in the future

Group i

Final ranking in group 1

Getting more knowledge about the research subject More knowledge related to the study topic More knowledge about a specific topic Group work makes the workload during the research process easier Personal relationships with participants during the study Improving research techniques and methods How to format a research question Knowledge about the research process Understanding the concepts of what research is all about Where to find accurate information Improvement of communication skills Teaches you to organise and plan information Learn to plan time more effectively Teach others the new information found Positive experience to convey knowledge to participants Good guidance of a study leader/supervisor Feeling valuable Build up confidence

i ii iii ii ii i i iii iii i i iii iii i ii ii i i

2 3 1 1 4 3 5b 2 4 4a 4b 3 5 4c 5 2 5a 5c

Cognitive • Skills development • Reflection • Administration • Benefits of research • Resources • Research process

Fig. 1. Categories identified in the nominal group technique discussions aligned with the tripartite model of attitude.

The behavioural component demonstrates how the students developed and matured. Participants acknowledged a broad range of skills that they felt had improved, including learning to deal with difficult interpersonal situations with group members and participants. The cognitive aspect specifies the higher-order thinking of linking theory to practice, understanding the limitations of the study and the benefits of what research could mean to them as individuals, the profession and their patients. The category of reflection spanned all three components of the tripartite model of attitude, from having a humble outlook, to altering behaviour, to co-operating with each other for the greater good of the team.

Discussion

This study revealed a cluster of negative statements related to the administrative concerns of the students. This finding has resulted in recommendations being made to the department (Table 3). Similar results were found in previous studies,[10-14] whereby benefits that accrued to students who performed research had a positive effect on their view of research in general. These benefits included a more positive attitude towards research,[10,12] increased interest in research,[10,12]

a better understanding of research design[11] and being more curious about research.[12] Research-related activities were also improved, such as the students’ skill level at library research skills development of research questions and hypotheses,[12] a greater understanding of data interpretation and the use of statistics in research,[11,12] as well as a better grasp of referencing.[12] Students perceived improved abilities in workplace skills. Participants mentioned creative thinking skills, application of ethical principles, computerbased knowledge and skills,[12] oral presentation skills, organisational skills and time management skills.[12,13] During the research process, students realised the importance of good time management, as well as learning to communicate well with others and share the workload. All of these skills lean towards flexibility, which is a sought-after quality in the working environment. The main negative aspect reported was the time-consuming nature of the research project owing to students being in different clinic groups. In 2015, the students were deliberately placed into clinic groups that matched their research project group. This allowed the students to have more time together to collate data. There were aspects where the Department of Optometry was perceived by the students as faring well: • presentations at annual faculty conferences • group work for research assignments • exposure to new equipment • earning credits towards one’s degree upon completion of the project • exposure to the literature as a source of learning • having an online arena for student discussions. Therefore, there are a number of aspects of the optometry programme that are being implemented correctly. The NGT discussions yielded valuable recommendations that, if implemented, would have the ability to instil a stronger research culture in the department.

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Research Table 2. The five topmost negative statements from the three nominal group technique groups with regard to their experiences of research Category Time related

Time related/administrative Resources Administrative

Administrative/time related Reflection Participants Participants/emotions Emotions

Statement Time consuming Time consuming Time consuming The process to obtain permission is time consuming Lack of resources Use of University of the Free State facilities increases the costs Ignorance relating to the administrative process during the research process Poor guidelines relating to the module No allocated time for research in the programme Uncertainty about the administrative processes The length of time the module takes (2 years) Missing data make analysis difficult Too complicated research question Subjects unwilling to participate Unwillingness of participants during the selection process Stressful What you put in is more than you get out

Group i ii iii ii i iii ii ii iii iii iii i i i ii i ii

Final ranking in group 1 2 4 2 2 3 3 4 1 5b 5a 4 5b 5a 5 3 1

Table 3. Recommendations: modification of current status Current status No protocol of communication between the departments involved in the research project

Statement Poor guidelines relating to the module; uncertainty about the administrative processes

Proposed change Formalised line of communication Drafting of rubrics for the presentation and the article to be submitted; these are to be included in the module guide

No formal schedule or responsibilities of team members delineated

Ignorance relating to the administrative process during the research process

Clear guidelines on deadlines and meetings with Leadership and commitment from the supervisor both parties A timeline for the study is to be included in the Accountability from members supervisor-student contract and responsibilities made transparent in this agreement

Research performed throughout the final year, as it suits the group members

No allocated time for research in the programme

Allocated week to perform research Groups for the research project share the same practical schedules

Students from various practical groups in the research group

Conclusion

The key recommendations resulting from the findings of the study were to implement policies in the Department of Optometry for better communication with students. Recommended strategies include the following: • allow students to choose their own groups within their clinic schedule • more dedicated research time in the schedule • provide guidelines that require the project to meet technical aspects of publication standards • quality assurance policy on supervision • workshops on writing for students to learn to compose research articles • share supervision with a senior researcher from a different department • allow staff to attend supervision workshops.

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Possible benefits Minimise time delays, reduce confusion and ambiguity of assessment Smoother planning for meeting outcomes

Shorter time span Concentrated effort allows for continuity of the research mindset Fewer clashes in the timetable, which allows for passive group members Less hassle for students to meet Fewer delays in the implementation of the research project

The new research module comprises eight credits. The outcomes provide a platform for greater emphasis on and importance of exit-level requirements. This study identified various factors that final-year students in the Depart ment of Optometry, University of the Free State, experienced positively and negatively in relation to the contribution of their attitude towards research. Acknowledgements. The authors would like to acknowledge the Health and Welfare Sector Education and Training Authority (HWSETA) for funding. Dr Daleen Struwig, Faculty of Health Sciences, University of the Free State, is acknowledged for technical and editorial preparation of the manuscript. Author contributions. SBK contributed to the study design and methodology, and LC conducted the study and compiled the manuscript.

Research Funding. Funding was granted by HWSETA. Conflicts of interest. None. 1. Den Hartigh W. Research output rises, papers double. 2012. www.mediaclubsouthafrica.com/tech/3038-sasresearch-output (accessed 10 February 2016). 2. Grossman ES, Naidoo S. Final-year South African dental student attitudes toward a research component in the curriculum. J Dent Educ 2009;73(11):1306-1312. 3. Chireshe R. Research supervision: Postgraduate students’ experiences in South Africa. J Soc Sci 2012;31(2):229234. https://doi.org/10.1080/09718923.2012.11893032 4. Portnoi L. To be or not to be an academic: South African graduate students. Int J Educ Dev 2009;29(4):406-414. https://doi.org/10.1016/j.ijedudev.2009.01.005 5. Krech D, Crutchfield RS. Perceiving the World in Theory and Problems of Social Psychology. New York: McGraw-Hill, 1948. 6. Schwarz N, Bohner G. Construction of attitudes. In: Tesser A, Schwarz N, eds. Blackwell Handbook of Social Psychology. Oxford, UK: Blackwell, 2001:436-457. 7. Olson MA, Kendrick RV. Attitude formation. In: Ramachandran VS, ed. Encyclopedia of Human Behavior. 2nd ed. New York: Elsevier, 2012:230-235.

8. Van Breda AD. Steps to analysing multi-group NGT data. Soc Work Pract Res 2005;17(1):1-14. 9. Harvey N, Holmes CA. Nominal group technique: An effective method for obtaining group consensus. Int J Nurs Pract 2012;18(2):186-194. https://doi.org/10.1111/j.1440-172X.2012.02017.x 10. McCoy M. Professional attitudes regarding research – changing the culture one student at a time. J Can Chiropr Assoc 2008;52(3):143-148. 11. Lei SA. Factors changing attitudes of graduate school students toward an introductory research methodology course. Education 2008;128(4):667-685. 12. Lei SA, Chuang NK. Undergraduate research assistantship: A comparison of benefits and costs from faculty and students’ perspectives. Education 2009;130(2):232-240. 13. Seymour E, Hunter AB, Laursen SL, DeAntoni T. Establishing the benefits of research experiences of undergraduates in the sciences: First findings in a three year study. Sci Educ 2004;88(4):493-594. https://doi. org/10.1002/sce.10131 14. John J, Creighton J. Researcher development: The impact of undergraduate research opportunity programmes on students in the UK. Stud Higher Educ 2011;36(7):781-797. https://doi.org/10.1080/03075071003777708

Accepted 21 December 2017.

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Research

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

Factors causing stress among first-year students attending a nursing college in KwaZulu-Natal, South Africa E M Langtree,1,2 MTech Nursing; A Razak,1 PhD; F Haffejee,3 PhD Department of Nursing, Faculty of Health Sciences, Durban University of Technology, South Africa Port Shepstone Campus, KwaZulu-Natal College of Nursing, South Africa 3 Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, South Africa 1 2

Corresponding author: F Haffejee (firozah@dut.ac.za)

Background. In South Africa (SA), there is a high failure rate of students in the first year of nursing and many drop out after this year, a precarious situation considering the shortage of professional nurses faced by the country. Academic success does not entirely comprise one’s application of intellectual capacity. Other factors may affect academic success, which could lead to stress, in turn hindering students’ academic potential. Objectives. To determine the stressors experienced by first-year nursing students who attended a college of nursing in SA and to ascertain the stressrelieving mechanisms used by these students. Methods. Student nurses (n=248) at a college of nursing in KwaZulu-Natal Province, SA, were required to complete a quantitative questionnaire. Data were collected between September and November 2013. Results. Long working hours, difficulty of academic work, poor study methods and family illness caused considerable stress. Family pressure to pay for necessities at home was also a factor that caused stress among the students. There was insufficient money to pay for textbooks for their studies. Stress-relieving mechanisms included playing with cell phones and socialising with friends. Lecturers, parents and fellow nursing students’ friends were a source of support. Conclusion. First-year nursing students experience a variety of stressors not directly related to their studies. Stress- and time-management workshops would be beneficial to these students. We also suggest that institutional support units be created to assist students in adjusting to the tertiary environment. Afr J Health Professions Educ 2018;10(2):90-95. DOI:10.7196/AJHPE.2018.v10i2.993

In South Africa (SA), higher education students exhibit progressively poor success rates.[1] The Council on Higher Education (CHE) observed that only 35% of all first-year entrants graduate within 5 years.[1] In KwaZulu-Natal (KZN) Province, SA, the majority of nurses are trained at a college of nursing, which has satellite campuses throughout the province.[2] There is, however, a high failure rate among these students, mostly in the first year of study. Because of academic failure, 22% of students leave the training programme after the first year[3]– a precarious situation, considering the shortage of professional nurses faced by the country.[4,5] In an attempt to address this high attrition rate, the admission criteria for entry into the programme were increased, but this did not have a noticeable influence on the pass rate. Students entering SA higher education institutions usually come from a wide range of cultural and social backgrounds, with resultant varying life experiences and educational opportunities, including different expectations, needs and academic potential.[6] Academic success does not entirely consist of one’s application of intellectual capacity. There are many other factors that directly or indirectly affect academic success. These include the transition from secondary school to university, student motivation, study methods, teaching strategies, interaction between students, academic and social systems of the university, cultural expectations, psychosocial factors and lack of finances.[7-10] One or more of these factors could lead to stress, which could hinder academic potential by distracting students’ focus from their studies.[11] Research has shown that self-concept positively affects the success of nursing students’ ability to manage anxiety and stress related to studying.

Specifically, if a student is confident in his/her ability and remains motivated, he/she is more likely to succeed academically, resulting in lower dropout rates. Whereas the overwhelming stress associated with test anxiety has a negative relationship with academic achievements, this could lead to a decrease in the academic success of students.[12] The nursing programme also contains both intensive coursework and practical components at hospitals, which may become overwhelming and stressful with regard to a student’s ability to cope with examinations.[12] Attrition rates among nursing students remain high, irrespective of attempts by institutions to provide strategies such as selection in line with quality of students, and implementing student mentoring and tutoring. It is unknown whether the stress factors that affect students attending a large university with many different faculties are different from those of students who attend smaller tertiary institutions that train them in one particular course only. In nursing, stress factors related to the clinical learning environment are well documented.[10,13,14] The increased stress of nursing students is due to the simultaneous learning in both academic and clinical areas. This adds to the growing personal stressors experienced by these students. Stress negatively influences students, thus affecting their academic performance and course completion rates.[15] Literature on stress that affects nursing students in small tertiary colleges in the early years of academic study is lacking. The objective of this study was to determine the stressors experienced by first-year nursing students who attended a college of nursing in SA. The study also ascertained the stress-relieving mechanisms used by these students.

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Research Methods

A quantitative descriptive survey design was used. Student nurses at a selected nursing college in KZN, who were either in the final stages of completing their first year of study or had done so in the previous semester, formed the target population (N=524) for this study. Using Cochrane’s formula, a minimum of 222 participants were required for the sample population to achieve significant results at a 95% confidence level. As we anticipated a response rate of ~80%, 267 students were targeted. Five campuses from 8 of the 9 campuses that comprise the nursing college were chosen for the study by a ballot method. The campuses differed only with regard to geographical distribution, which allows for easy access to students from different parts of the province. The campus at which the principal investigator (EML) lectures, was excluded from the study. The criteria required for inclusion in the study were: first-year nursing students enrolled for a minimum of 7 months at the college, who understood the letter of information and signed the consent form. All students at the 5 campuses who met the inclusion criteria were invited to participate in the research study. Participation was voluntary and no students were forced into entering the study. All students were provided with information about the study, both verbally and on an information sheet. Students who agreed to participate after reading the information letter, signed a consent form prior to answering the self-administered questionnaire. A new questionnaire was developed, as an appropriate one was not available for the purposes of this study. The questionnaire was also used as part of a larger study. It was developed by the researcher (EML) from four common themes, in addition to a section on demographic data. The themes included: English as a second language, first-generation students, stressors experienced by students and programme orientation. There was a total of 76 questions, of which 48 were used for this part of the study. These included simple dichotomous questions for demographics, questions using rating and ranking scales and Likert scale-type questions. A combination of different types of questions increases the reliability and validity of the tool.[16] Participants were asked to respond to statements about factors that cause stress, by selecting 1 of 5 stress levels in response to each statement. The levels of stress were scored from 1 (not at all stressful) to 5 (very stressful). Students were also asked to consider statements about factors to relieve stress and indicate their choice according to a Likert scale, from 1 (strongly disagree) to 5 (strongly agree). After construction of the questionnaire, a focus group discussion was held to ensure validity of the questionnaire. The focus group discussion took place during the departmental research committee meeting, which comprised 6 academics, 5 of whom are also professional nurses and 1 who is not a nurse but a staff member at the Faculty of Health Sciences. This group of experts in nursing and health science education and research was invited to judge each item in the questionnaire for relevance, clarity, simplicity and ambiguity. Items that did not adequately meet these criteria were either removed from the questionnaire or adjusted until acceptable. The post-focus group questionnaire was then piloted for reliability with 5 students who met the inclusion criteria for the study, but who were excluded from the main study. The purpose of the pilot study was to detect flaws, establish usefulness of the questions and, if necessary, amend the questions. The pilot study population indicated that they understood the questions and did not have difficulty in answering them; therefore, no changes were made to the questionnaire.

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Data were collected between September and November 2013. An academic not involved in the research distributed the questionnaires and was available in the classroom to answer any queries that the students might have had. The researcher was available in a nearby room to answer any queries of respondents if necessary. She was not in the classroom, in an effort to prevent students feeling obligated to participate in the study. All participants were required to sign a consent form prior to answering the questionnaire. No students were coerced into participating. Data were analysed on SPSS version 17 (SPSS Inc., USA) by means of frequency distribution of responses and mean scores. To test for significant trends in the data, inferential statistics were applied. These included Pearson’s correlation and χ2 tests. Wilcoxon signed-rank tests were used for the comparison of non-parametric data. Throughout, p<0.05 was used to indicate significance.

Ethical approval

The study was approved by the Durban University of Technology Institutional Research Ethics Committee (ref. no. IREC 052/13). Permission to conduct the study at the nursing college was obtained from the KZN Department of Health and the acting principal of the college.

Results

Participant demographics

Of the 267 questionnaires distributed, 248 were completed, giving a response rate of 92.8%. Participant demographics are indicated in Table 1. Table 1. Participant demographics Demographics Gender Female Male Age category, years 19 - 20 21 - 22 23 - 24 24 - 25 ≥26 Race Black African Indian Coloured White Home language isiZulu English isiXhosa Afrikaans Other African language Area raised Rural Urban Type of secondary school attended Rural government Urban government Peri-urban government /township Private

Participants, n (%) 174 (70.2) 74 (29.8) 41 (16.5) 42 (16.9) 48 (19.4) 41 (16.5) 75 (30.2) 215 (86.7) 22 (8.9) 10 (4.0) 1 (0.4) 195 (78.6) 33 (13.3) 7 (2.8) 1 (0.4) 12 (4.8) 152 (61.3) 96 (38.7) 115 (46.4) 66 (26.6) 55 (22.2) 12 (4.8)

Research The majority were female (70.2%; n=174), ˂26 years of age (69.6%; n=75), of black ethnicity (86.7%; n=215) and raised in a rural area (61.3%; n=152). Although 71% (n=175) were raised by their own parents, 22% were raised by extended family members, a social welfare home (4%), a child-headed household (2%) or members of the community (1%). The type of secondary school attended varied significantly between the different participants (p<0.001), with almost half having attended a rural government school (46.4%). Many were the first in their family to attend a tertiary education institution (37.5%; n=93). Half of the respondents indicated that they had basic necessities, such as electricity, clean water and adequate food, in their homes (52.4%; n=130), but that there was nothing extra available. Only a quarter (23%; n=57) always had the basic necessities and a little extra money available. Some did not have any basic necessities (18.5%; n=46) and only a few respondents (4.4%; n=11) always had everything that they wanted in their homes. For the duration of their nursing studies, all of the respondents had the opportunity to live in a nurses’ residence (100%; n=248).

Stressors experienced by first-year students

Respondents were asked to consider statements relating to factors that cause stress by selecting 1 of 5 levels in response to each statement. The overall results are presented in Table 2. The levels of stress were scored from 1 (not at all stressful) to 5 (very stressful). The long working hours, financial pressures,

assignments, difficulty of academic work, poor study methods, family illness and other problems at home caused considerable stress (mean >3; p<0.001). They were also required to contemplate the level of agreement to statements related to factors that may cause stress. These levels of agreement were scored from 1 (strongly disagree) to 5 (strongly agree). The overall results are presented in Table 3. The majority of respondents felt that they did not have enough time for their studies, that they had to work harder than their classmates and that they experienced more stress than their classmates. They also indicated that there was family pressure to pay for necessities at home and that there was insufficient money to pay for textbooks for their studies. Furthermore, stress affected their grades negatively (mean >3; p<0.001). The transition from secondary school to tertiary education was difficult (Table 4). Respondents felt that they did not know what was awaiting them before starting the nursing course (n=247; p<0.001). They felt that nursing was not what they had expected (n=246; p=0.038), and had anticipated the nursing programme to be more practical than theoretical (n=246; p<0.001). Most respondents also expected ‘nursing to be an easy practical job’ (n=246; p<0.001). However, the choice of another course at university did not take precedence over the nursing course (n=246; p<0.001) and they were not studying nursing merely to receive a monthly salary – it was what they wanted to do (n=246; p<0.001).

Table 2. Distribution of responses to factors that may cause stress Levels of stress Stress factor Academic assignments Long working hours Difficulty of academic work Poor study methods Personal illness Family illness Other problems at home Living away from home Financial pressures

Not at all stressful, n (%) 13 (5.3) 6 (2.4) 21 (8.7) 39 (16.0) 66 (26.9) 47 (19.1) 31 (12.6) 69 (28.4) 17 (6.9)

A little stressful, n (%) 65 (26.4) 33 (13.4) 55 (22.7) 51 (20.9) 69 (28.2) 47 (19.1) 60 (24.3) 59 (24.3) 42 (17.0)

Stressful, n (%) 76 (30.9) 56 (22.7) 83 (34.3) 68 (27.9) 44 (18.0) 69 (28.0) 57 (23.1) 37 (15.2) 47 (19.0)

Rather stressful, n (%) 38 (15.5) 19 (7.7) 28 (11.6) 26 (10.7) 15 (6.9) 14 (5.7) 32 (13.0) 19 (7.8) 15 (6.1)

Very stressful, n (%) 54 (22) 133 (53.9) 55 (22.7) 60 (24.6) 51 (20.8) 69 (28.0) 67 (27.1) 59 (24.3) 126 (51.0)

Mean 3.22 3.97 3.17 3.07 2.66 3.04 3.18 2.75 3.77

Table 3. Levels of agreement with regard to factors that cause stress Statement My family does not understand the time and energy required for successful studies I have more stressors than my classmates I do not have enough time in the day to complete all the necessary tasks I feel that I do not belong studying this nursing programme Stress affects my grades negatively I have family pressure to pay for necessities at home I don’t have enough money to pay for textbooks In order to pass, I have to study longer hours than my classmates

Strongly disagree, n (%) Disagree, n (%) 81 (32.6) 81 (32.6)

Neither agree nor disagree, n (%) Agree, n (%) 13 (5.2) 49 (19.8)

Strongly agree, n (%) 24 (9.7)

Mean 2.4

20 (8.1) 10 (4.1)

74 (29.8) 77 (31.2)

44 (17.7) 35 (14.2)

78 (31.5) 99 (40.1)

32 (12.9) 26 (10.5)

3.1 3.2

96 (38.9)

100 (40.5)

23 (9.3)

19 (7.7)

9 (3.6)

2.0

11 (4.5) 30 (12.1) 17 (6.9) 9 (3.6)

61 (24.7) 72 (29.0) 55 (22.3) 47 (19.0)

32 (13.0) 18 (7.3) 26 (10.5) 38 (15.3)

103 (41.7) 81 (32.7) 84 (34.0) 91 (36.7)

40 (16.2) 47 (19.0) 65 (26.3) 63 (25.4)

3.4 3.2 3.5 3.6

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Research Stress-relieving mechanisms

A significantly large proportion of respondents played with their cell phones (p<0.001) or socialised with their friends (p<0.001) to alleviate stress. Eating, consumption of alcohol/partying and staying away from work were not used as stress relievers by most of the participants. The overall results for the coping mechanisms are presented in Table 5. Respondents were asked to use a Likert rating from 1 to 5 to indicate the support that they received from specified sources, from 1 (not at all) to 5 (a great deal). A mean score was calculated. Most respondents felt that their lecturers (mean 4.17 (standard deviation (SD) 1.27); n=246), parents (4.00 (1.52); n=241) and friends (fellow nursing students) (3.78 (1.44); n=246) were sources of support. To a lesser extent, respondents identified their siblings (3.22 (1.70); n=245), friends from school (3.06 (1.61); n=245) and close relatives (2.63 (1.63); n=246) as sources of support.

Discussion

This study ascertained the factors that cause stress among first-year nursing students attending a college of nursing in SA. Our findings indicate that academic commitments, family finances and illness increase the outcome of stress. It is expected that the transition from a secondary to a tertiary level

of education leads to longer hours of study and having to deal with subject material of a more difficult nature. Students entering tertiary institutions should be provided with mentoring workshops that help them to cope with these stressors. It is also recommended that implementation of intervention strategies is required in institutions to educate students on developing study skills to manage stress-related factors. Programmes that provide academic support should include academic, self-concept and motivational factors[12] that assist in this management. Mentoring by senior peers allows students to realise that this is part of the normal learning process and also offers guidance on dealing with these difficulties. Studying skills can be incorporated into these mentoring workshops, as the respondents indicated that their studying skills were poor, which also caused stress. Furthermore, these stressors led them to obtain poor grades. As previously pointed out, stressors related to poor college preparation and poor study skills are common.[11] Most respondents found the long working hours very stressful and they did not have sufficient time to complete tasks related to their studies. Other reports indicate that a lack of time contributes to students feeling stressed.[17] Curriculum planning in tertiary institutions needs to ensure that academic overload does not occur and that sufficient time is provided

Table 4. Levels of agreement with regard to orientation into tertiary education Statement I knew what I was getting into before starting the nursing course I am studying nursing to get a monthly salary I wish I had rather studied another course at university Nursing is not what I expected it to be I thought nursing would be more practical; I didnâ&#x20AC;&#x2122;t know it would be so academically difficult I expected nursing to be an easy, practical job At nursing college, the study culture is more difficult than in high school At nursing college, it is more difficult to achieve well academically At nursing college, there is a lot more work to do in a short time At nursing college, the method of teaching is different and faster

Strongly disagree, n (%) Disagree, n (%) 65 (26.3) 69 (27.9)

Neither agree nor disagree, n (%) Agree, n (%) 21 (8.5) 60 (24.3)

Strongly agree, n (%) 32 (13.0)

Mean 2.7

84 (34.2) 79 (32.1)

104 (42.3) 86 (35.0)

33 (13.4) 40 (16.3)

16 (6.5) 26 (10.6)

9 (3.7) 15 (6.1)

2.0 2.2

37 (15.0) 18 (7.3)

49 (19.9) 28 (11.4)

23 (9.4) 18 (7.3)

100 (40.7) 104 (42.3)

37 (15.0) 78 (31.7)

3.2 3.8

20 (8.1) 5 (2.0)

46 (18.7) 30 (12.2)

25 (10.2) 15 (6.1)

94 (38.2) 122 (49.4)

61 (24.8) 75 (30.4)

3.5 3.9

6 (2.4)

57 (23.1)

34 (13.8)

117 (47.4)

33 (13.4)

3.5

1 (0.4)

7 (2.8)

9 (3.6)

103 (41.7)

127 (51.4)

4.4

4 (1.6)

30 (12.2)

29 (11.7)

113 (45.8)

71 (28.8)

3.9

Strongly agree, n (%) 19 (7.7) 43 (17.4) 52 (21.2) 43 (17.5) 16 (6.6) 8 (3.3) 42 (17.0) 11 (4.5)

Mean 2.5 3.2 3.5 3.0 2.4 1.7 3.2 2.1

Table 5. Levels of agreement with regard to stress-coping mechanisms used by students I deal with stress by â&#x20AC;Ś Eating Playing on my cell phone Socialising with friends Keeping to myself Crying and complaining Drinking alcohol/partying Exercising Staying home from work

Strongly disagree, n (%) 65 (26.3) 27 (10.9) 27 (11.0) 31 (12.6) 68 (27.9) 144 (58.8) 35 (14.2) 98 (39.7)

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Disagree, n (%) 79 (32.0) 62 (25.1) 34 (13.9) 77 (31.3) 86 (35.3) 63 (25.7) 52 (21.1) 85 (34.4)

Neither agree nor disagree, n (%) 26 (10.5) 26 (10.5) 19 (7.8) 31 (12.6) 20 (8.2) 17 (6.9) 36 (14.6) 24 (9.7)

Agree, n (%) 58 (23.5) 89 (36.0) 113 (46.1) 64 (26.0) 54 (22.1) 13 (5.3) 82 (33.2) 29 (11.7)

Research for the completion of tasks. Time-management workshops can alleviate such problems, particularly if these are held early in the students’ first year at college. Moreover, if time is adequately managed by students, there could be an indirect improvement of their grades. Recent studies indicated that group work is beneficial to students in the health sciences, with students gaining an enhanced understanding of the subject matter when working with their peers.[18,19] Group work may also be beneficial in time management. Brief activities or larger assignments of a collaborative nature will make learning enjoyable[19] and hence alleviate stress. Despite receiving a bursary of ZAR3 000 (USD214) per month for the duration of their training, finances were a source of stress. While financial stress has previously been documented,[10] a novel finding of this study was that although students were living away from home, they felt that there was family pressure to pay for basic necessities at home. Even though their families understood the time and energy required for their studies to be successful, there was nevertheless the expectation of payment towards household expenses, as essential items are often lacking in their homes, particularly for students from rural backgrounds and of low socioeconomic status. This would be a common dilemma faced in developing countries and would be further exacerbated for first-generation students. The students also indicated that despite receiving bursaries for their studies, there was insufficient money to purchase textbooks from these funds. It is possible that these students use part of their funds for household expenses. Some students indicated that illness experienced by family members, problems at home, personal illness, and living away from home caused stress. This, yet again, demonstrates the closely-knit families from where the students come. It may also be indicative of a constant presence of illness, which may be of a serious nature. The incidence of HIV in KZN is among the highest in the world and its impact on the health of the SA workforce has a negative effect on the motivation and performance of this workforce.[20,21] Thus, motivation and performance of students are also affected by HIV infection of family members. Nevertheless, students do find ways of alleviating stress; one of the most important ways is socialising with friends. This concurs with reports that social support from others lessens stress.[22] Such social support is also correlated with academic success.[22] However, previous reports show that first-generation students tend to isolate themselves from others, particularly academics, when stressed.[23] Our finding that lecturers are a source of support, is therefore encouraging. It indicates that current students are more willing to adapt to the study environment, are trying to fit into the academic environment and are not shy to turn to their lecturers for support. The creation of a student-friendly environment is therefore beneficial for both the academic and social needs of students. As all the respondents were living in the student-nurse hostel, a family support system for coping with stress was absent and they therefore turned to academic staff when support was required. Institutional support groups may provide additional aid to students who have difficulty in adjusting to the university environment. Students may not understand the method of pedagogy at higher education level. Teaching strategies at tertiary level are not widely understood by students, resulting in difficulty in adapting to specific programmes. Therefore, institutional support that assists students to adjust to the tertiary environment is likely to improve completion rates. Our findings revealed that a significant proportion of respondents redirected their attention to cell phones as a way of dealing with stress. This is another novel finding and is in contrast to reports that cell phone

usage increases stress.[24] This could possibly be related to the current use of cell phones for social networking, accessing the internet, watching and sharing of videos, as well as playing video games[25] – in addition to the use of cell phones for making telephone calls and text messaging. The former uses could be beneficial, particularly regarding social networking, as social support helps to relieve stress.[22] However, such use could possibly be detrimental if it occurs during lectures, as the user will be distracted, leading to less academic information being gained. A limitation of this study is that we did not enquire about the duration of cell phone usage. Notably, very few respondents reported drinking and binge eating as stress-relieving mechanisms, which is a very encouraging finding. Previous reports show that first-generation students are less likely to use socialcoping strategies such as drinking and partying to manage their stress,[22] which supports our findings. Mentoring programmes should reinforce these behaviours to ensure that future students do not resort to alcohol consumption. It is also promising that students used exercise as a stressrelieving mechanism. Although this study was conducted at a college of nursing in KZN, the results can be generalised to universities in SA, as the majority of firstyear students at these tertiary institutions appear to come from similar backgrounds.

Conclusion

Our findings indicate that in addition to academic commitments, financial pressures and illness that affect the families of students are a major source of stress among first-year nursing students in SA. Students tend to socialise with friends and play with cell phones to relieve stressful situations. In addition to friends, lecturers were a source of support. We suggest that the incorporation of stress and time management into the curriculum would be beneficial to first-year nursing students. We also propose that institutional support units should be created to assist students in adjusting to the tertiary environment. Acknowledgements. We acknowledge support from the Durban University of Technology towards EML’s research project for the Master of Technology (Nursing) degree. Author contributions. EML collected the data and wrote the first draft of the manuscript. AR and FH supervised the project, edited the manuscript and approved the final article. Funding. Durban University of Technology funding for Masters’ students. Conflicts of interest. None. 1. Council on Higher Education. A Proposal for Undergraduate Curriculum Reform in South Africa: The Case for a Flexible Curriculum Structure. Pretoria: CHE, 2013. 2. South African Nursing Council. South African Nursing Council statistics: Annual statistics. 2011. http://www. sanc.co.za/stats_an.htm (accessed 12 May 2013). 3. Hopkins TH. Early identification of at-risk nursing students: A student support model. J Nurse Educ 2008;47(6):254-259. https://doi.org/10.3928/01484834-20080601-05 4. Buchan J, Aiken L. Solving nursing shortages: A common priority. J Clin Nurse 2008;17(24):3262-3268. https:// doi.org/10.1111/j.1365-2702.2008.02636.x 5. Mokoka E, Oosthuizen MJ, Ehlers VJ. Retaining professional nurses in South Africa: Nurse managers’ perspectives. Health SA Gesondheid 2010;15(1):1-9. https://doi.org/10.4102/hsag.v15i1.484 6. Chikte U, Brand A. Diversity in South African dental schools. J Dent Ass S Afr 1996;51(10):641-646. 7. Fraser WJ, Killen R. Factors influencing academic success or failure of first-year and senior university students: Do education students and lecturers perceive things differently? S Afr J Educ 2003;23(4):254-263. 8. Murray M. Factors affecting graduation and student dropout rates at the University of KwaZulu-Natal. S Afr J Sci 2014;110(11-12):1-6. https://doi.org/10.1590/sajs.2014/20140008 9. Stephen D, Welman J, Jordaan W. English language proficiency as an indicator of academic performance at a tertiary institution. S Afr J Hum Resource Manage 2004;2(3):42-53. https://doi.org/10.4102/sajhrm.v2i3.48 10. Timmins F, Kaliszer M. Aspects of nurse education programmes that frequently cause stress to nursing students – fact-finding sample survey. Nurse Educ Today 2002;22(3):203-211. https://doi.org/10.1054/nedt.2001.0698 11. Starr K. Nursing education challenges: Students with English as an additional language. J Nurse Educ 2009;48(9):478-487. https://doi.org/10.3928/01484834-20090610-01

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Research 12. Khalaila R. The relationship between academic self-concept, intrinsic motivation, test anxiety, and academic achievement among nursing students: Mediating and moderating effects. Nurse Educ Today 2015;35(3):432-438. https://doi.org/10.1016/j.nedt.2014.11.001 13. Clarke VA, Ruffin CL. Perceived sources of stress among student nurses. Contemp Nurse 1992;1(1):35-36. https:// doi.org/10.1080/10376178.1992.11001462 14. Lindop E. Individual stress among nurses in training: Why some leave while others stay. Nurse Educ Today 1991;11(2):110-120. https://doi.org/10.1016/0260-6917(91)90146-2 15. Turner K, McCarthy VL. Stress and anxiety among nursing students: A review of intervention strategies in literature between 2009 and 2015. Nurse Educ Pract 2017;22:21-29. https://doi.org/10.1016/j.nepr.2016.11.002 16. Burns N, Grove S. The Practice of Nursing Research: Appraisal. Synthesis and Generation of Evidence. 6th ed. St Louis: Saunders Elsevier, 2009. 17. Watkins KD, Roos V, van der Walt E. An exploration of personal, relational and collective well-being in nursing students during their training at a tertiary education institution. Health SA Gesondheid 2011;16(1):1-10. https:// doi.org/10.4102/hsag.v16i1.552 18. Van Wyk J, Haffejee F. Benefits of group learning as a collaborative strategy in a diverse higher education. Int J Educ Sci 2017;18(1-3):158-163. https://doi.org/10.1080/09751122.2017.1305745 19. Haffejee F, van Wyk J, Hira V. Use of role-play and community engagement to teach parasitic diseases. Afr J Health Professions Educ 2017;9(2):51-53. https://doi.org/10.7196/AJHPE.2017.v9i2.673

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20. Nel A, Mabude Z, Smit J, et al. HIV incidence remains high in KwaZulu-Natal, South Africa: Evidence from three districts. PLOS ONE 2012;7(4):e35278. https://doi.org/10.1371/journal.pone.0035278 21. Tawfik L, Kinoti SN. The Impact of HIV/AIDS on the Health Workforce in Developing Countries. Geneva: World Health Organization, 2006. 22. Mehta SS, Newbold JJ, O’Rourke MA. Why do first-generation students fail? Coll Student J 2011;45(1). 23. Paulynice R. What causes many college students to fail or drop out? 2011. https://hubpages.com/education/ What-Causes-College-Students-to-Fail-or-Dropout#comment8223407 (accessed 6 August 2013). 24. Thomée S, Härenstam A, Hagberg M. Mobile phone use and stress, sleep disturbances, and symptoms of depression among young adults – a prospective cohort study. BMC Public Health 2011;11(1):66. https://doi. org/10.1186/1471-2458-11-66 25. Lepp A, Barkley JE, Karpinski AC. The relationship between cell phone use, academic performance, anxiety, and satisfaction with life in college students. Compute Hum Behav 2014;31:343-350. https://doi.org/10.1016/j. chb.2013.10.049

Accepted 12 October 2017.

Research

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

‘Pain and stress are part of my profession’: Using dental practitioners’ views of occupation-related factors to inform dental training R Moodley,1 B Dent Ther, MSc Dent Pub Health; S Naidoo,2 MB ChB, PhD; J van Wyk,3 BSc (Ed), MEd, PhD 1

Discipline of Dentistry, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

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

Discipline of Clinical and Professional Practice, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: R Moodley (moodleyra@ukzn.ac.za)

Background. Stress is prevalent among dental workers and students. A possible means to address this would be to include stress management programmes in undergraduate dental programmes. The purpose of this study was to establish how the current cohort of dental practitioners incorporate occupational health and self-care principles into professional practice, and their potential relevance to future curriculum design. Objectives. To gain input from participants regarding stress and burnout – their causes, implications and prevention – as linked to their practice in dentistry. Methods. A qualitative research design was used, with a purposive sampling technique. The study population consisted of dentists, dental therapists, hygienists and specialists. A total of 36 participants participated in four focus-group discussions to explore dental education, occupational health, stress and self-care. The data were thematically analysed. Results. Dental training in the South African context, occupational health experiences, self-care, coping strategies and education were the main themes that emerged. Dental services in the public sector were reported to be overwhelmed by high patient volumes and shortages of staff and resources, which added to these stressors. The coping strategies adopted were exercise, stretching, reducing workload and encouraging teamwork. The participants believed that the causes of musculoskeletal disorders, and their impact, should be taught in dental training, as students do not perceive this as a potential problem. A multidisciplinary approach and teamwork training are the recommendations for curricula. Conclusion. Stress management techniques and workplace posture assessment should be taught in preclinical training to make students aware of managing stress and correct working postures. A multidisciplinary approach should be used. Dental curricula should include occupational health safety principles. Afr J Health Professions Educ 2018;10(2):96-100. DOI:10.7196/AJHPE.2018.v10i2.1005

Stress is prevalent among both dental workers and students. A study conducted among dental students in Malaysia found a 100% prevalence of stress.[1] Dental students’ stress relates to their expectations of high academic achievements and excellence based on their previous academic records at school. The 5-year curriculum is stressful, with each successive year of study having a significant impact on the stress levels of students. This high level of stress in dental students calls for the implementation of stress management programmes in dental education.[2] Dental education should serve as the starting point for the establishment of a healthy workplace that is free of stress. A healthy work environment is a valuable asset to a worker. It can sustain a healthy and productive work life, lowering incidences of work-based injuries and stress. Occupational health is not just an important factor in the personal health of the worker; if all principles are followed, it will improve productivity and work quality, increase work motivation, improve job satisfaction and improve the overall quality of life of the individual.[3] The dental workforce involved with treating patients directly in South Africa (SA) is comprised of dentists, dental therapists, oral hygienists and specialists. For the purposes of this article, they will collectively be referred to as dental practitioners. Dental practitioners provide oral healthcare services in both the public and private sectors in SA.

A study conducted at an SA dental school revealed that most of the students experienced stress, with 45% showing signs of moderate stress and 42% severe stress. Nearly a quarter (25%) of the respondents wanted to quit or change courses, and a significant 3% (n=6) wanted to commit suicide. The researchers recommended that stress management be included early in the curriculum to equip students to deal with stress.[4] This is supported by research among newly qualified dentists in Hong Kong. The authors recommended that stress management be added to the curriculum, and stress management updates held for newly qualified dentists.[5] The purpose of the present study was to establish how the current cohort of dental practitioners incorporate occupational health and self-care principles into professional practice, and their relevance to curriculum design. The objective of this study was to gain input from participants regarding stress and burnout – causes, implications and prevention measures – linked to their practice in dentistry.

Methods

This was a qualitative study conducted among dental practitioners in various fields, regarding their occupational health. The study was conducted in KwaZulu-Natal (KZN), SA. A purposive sampling technique was used to identify participants. Data were collected

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Research through focus-group discussions with dental practitioners. Four focusgroup discussions were conducted between May and June 2017. A total of 36 dental practitioners participated in these focus-group discussions, which were conducted by the researcher (the first author). The focus-group discussions explored dental education, occupational health, stress and selfcare. Each session lasted between 60 and 90 minutes. This study forms part of a larger project. Ethical clearance was obtained from the Humanities and Social Sciences Research Ethics Committee of the University of KZN (ref. no. HSS/1490/015D). Written informed consent was obtained from all participants, who were informed of their right to withdraw from the study at any stage. All participants agreed to participate and to have an audio recording made of the interview. Anonymity of participants was maintained throughout the study by using participant codes instead of names. The participants filled out an anonymous demographic information sheet. The audio recordings were transcribed verbatim, and the transcripts checked for accuracy. Member check, or respondent validation, was conducted to establish validity. The data were then analysed thematically. Broad themes were identified, according to the main aim, and then further refined and coded until the final analysis was complete.[6] The themes identified were analysed in line with the objectives of this study.

Results

Five main themes were identified, based on the questions that were explored. The themes were identified, refined and grouped. Dental training in the SA context, occupational health experiences, self-care and burnout, coping strategies and dental education were the main themes identified. Dental training is hindered by lack of resources, lack of staff, focus on curative work and a lack of teamwork, all of which impact on the stress levels of staff and students. A brief description of each theme is given, followed by illustrative quotes (Tables 1 - 5).

Discussion

Dental practice in the current SA healthcare system is hindered by shortages of resources and staff, and equipment in facilities, and by malfunctioning dental chairs. The poor conditions in the clinical context are exacerbated by high volumes of patients. When dental staff are pressured into working long hours owing to high patient volumes, it impacts on their health, with repetitive tasks exacerbating the situation. Occupational stresses place the workers at risk of musculoskeletal disorders (MSDs). Repetitive tasks cause muscle fatigue and increase the use of joints, predisposing dental workers to joint injuries.[7,8] Comments from the practitioners showed that the development of a healthy workplace environment and practice should be prioritised to prevent work-based injuries. Poor working conditions, staffing problems and time pressures are common stressors. In a poorly resourced dental clinic, the stressors are greater, as is their impact on health.[9] Improving the work environment, supplemented by increasing access to resources, can improve morale and dedication among dentists. Job-enrichment strategies can be used to improve communication and facilitate contact among colleagues. Hakanen et al.[10] suggest promoting an increased variability of skills, which is unfortunately not the case among practitioners in KZN, as many of them perform mainly curative tasks. Early retirement of staff, long-term sick leave, loss in productivity, loss of income and increased need for medical care are some of the implications of occupational health-related conditions.[11] One of the stressors that was strongly recognised in this study was lack of teamwork. Teamwork skills should be taught, and assessed as one of the core competencies to achieve during dental training; moreover, these skills should be learnt and practised during training. Working in a team reduces stress and creates a sense of value for workers. ‘Learning together’ for all oral healthcare students would foster teamwork.[12] Dental training occurs at various clinics in KZN. Dental practitioners are not trained together

Table 1. Dental work in the South African context Subtheme Public sector dental services are overwhelmed by high patient volumes, compounded by a shortage of staff.

The public sector is hindered by a lack of structural resources. There is a marked divide between the services offered in the public and private sector in terms of patient numbers, resources and patient care, which affects service delivery. Resource constraints affect service delivery and practitioner wellbeing

Dental staff were disillusioned, as there was a lack of upward employment mobility.

Aircon = air conditioning.

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Quotes ‘Like in our place, you’re looking at the public sector and we are short-staffed. So the number of patients is a problem. So you haven’t got time for quality work.’ (Focus group 1, participant 3) ‘I think the whole structure of the oral health system – it really needs to be shaken up. Why are we seeing so many extractions?’ (Focus group 1, participant 1) ‘Also at our place we are having a problem with the aircon. And all the windows are sealed in the hospital … There are days when it’s extremely hot.’ (Focus group 1, participant 3) ‘So the profile of the patient dictates in some way … it means you have to adhere to their requests and prioritise them. And that is in private. But in public, you still have the larger numbers.’ (Focus group 1, participant 6) ‘In the current institute where I am, we have two chairs but they are not fully equipped. So we can do crowns, but we cannot do scaling so we only doing extractions. I worked there in a 7-month period and I ended up hurting my arm because of the repetitive nature. I went from working properly to doing no extractions at all.’ (Focus group 1, participant 4) ‘Healthy operator equals healthy economy. An operator is more useful to government working throughout their career.’ (Focus group 1, participant 6) ‘There is no growth once you enter the public sector, there is no room for growth.’ (Focus group 3, participant 2) ‘So no upward mobility as such even if you’re kind of looking with binoculars.’ (Focus group 3, participant 8).

Research Table 2. Occupational health experiences in dental work Description Individual experiences as practitioners lead to various experiences with respect to the diagnosis of their occupational health disorders.

Quotes ‘I worked for 20 years before I started experiencing my problems. And I think I worked myself to such a point where I couldn’t do it anymore. So I ignored the physical symptoms until I realised it was affecting the quality of my work. It did impact on the quality of my life.’ (Focus group 1, participant 4) ‘And this is after 19 years and I kept telling my colleague that I had pain. I couldn’t move my shoulder. I just couldn’t move. Every time I did, there was pain … But I started getting pain going down my arm, so I went for physio[therapy] and to see an orthopaedic. I told him about the extractions I do, so he put me off for a month.’ (Focus group 1, participant 3) ‘Dr A ended up with a musculoskeletal problem. 2014/15 she was doing her community service; she left after completion. Luckily, she was able to get permission to do a maximum of 40 per day before she left. Dr B – shoulder is compromised resulting in her being unable to do extractions! Dr C also suffers from wrist problems. There were days when we were tasked to do 90-odd patients.’ (Focus group 1, participant 6)

Table 3. Self-care and burnout Description Lack of collegiality and teamwork was an issue that had an impact on stress levels.

Quotes ‘You work with people who know you for who you are and they start questioning you. That was very disappointing.’ (Focus group 1, participant 4) ‘I think when you’re working, each one must give their pound of flesh kind of thing. So it’s kind of why am I doing your work kind of thing. (Focus group 1, participant 4) ‘You feel like you not pulling your weight. Because when you want to do something but your hands are shaking like that, you feel like you can’t do it, but you’ll still do it anyway because you don’t want to feel like you’re not doing your job. So I think I will change my career, definitely. I have to change, because I have seen it. My uncle who’s a maxillofacial surgeon also had to stop work. So it’s scary for me.’ (Focus group 1, participant 2)

Table 4. Coping strategies Description Self-adopted coping strategies

Quote(s) ‘Now when I wake up, I stretch in the morning and it really has made a big difference, so we need to educate the students about this.’ (Focus group 1, participant 3) ‘I saw my 15, you must see your 15. So that’s fair. We must share the workload, that’s our motto.’ (Focus group 1, participant 3) ‘I was just doing scripts when I was in pain. I saw a physiotherapist, orthopaedic and a chiropractor.’ (Focus group 3, participant 9) ‘Without the swimming, without the Pilates, without physiotherapy, without lumbar corsets being put on myself, I would not be sitting here working. I would not be sitting here right now.’ (Focus group 4, participant 4)

as a healthcare team at UKZN, since the institution currently only offers two programmes – dental therapy and oral hygiene. While the therapists and oral hygienists seemed to get along, this was not the case with dentists who may have trained at various other institutions in the country. In a study by Rafeek et al.,[13] students were prepared for and seemed confident in restorative and preventive dentistry, but not in practice management and teamwork. Dental curriculum development should focus more on the affective skills that are required after graduation. A study on teamwork in the UK showed that dental therapists felt valued, supported and consulted as part of a full dental team. However, in some cases, dental therapists felt that dentists were not listening to them, and that as therapists, they were given

more preventive than restorative tasks. The dentists did not know the scope of dental therapy practice.[14] Caring for patients was a priority for dental practitioners in the present study, and they treated patients who were experiencing pain. The dental practitioners in this focus group prioritised the health of the patients over their own, and this caused them further injury. Self-recognition and recognition of health problems should therefore be added to undergraduate training. The caregiver’s role was investigated in a study by Leka and Jain,[15] and it was found that dentists idealised caring for and healing others. Job content, lack of variety of work, underuse of skills and uncertainty of work conditions were identified as psychosocial risk hazards associated with

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Research Table 5. Dental education Subtheme Students were actively discouraged from the profession

Quote(s) ‘When the students come in, we literally scare them away from the profession because they look at me and I tell them what happened to me and they then think, should I be doing this?’ (Focus group 1, participant 4) Participants made suggestions about dental training ‘A physical stretching session, get staff from various disciplines to assist.’ (Focus group 1, participant 4) ‘We need to talk about assertiveness training, like how do you assert your own limitations.’ (Focus group 1, participant 6) ‘Teach the causes of the MSD and its impact.’ (Focus group 4, participant 1) Students were seen as not interested in their own health and ‘I have seen a lot of times that the students just don’t stand in the right positions. I go showing a lack of interest in self-care; they did not understand the to them and I tell them how to stand and what happens if you don’t stand the right way. implications of occupational hazards So I keep correcting them. The students say they want to sit where they can visually see everything, but the body posture is wrong.’ (Focus group 1, participant 3) MSD = musculoskeletal disorder.

the practice of dentistry in KZN. Furthermore, the lack of control over one’s workload exacerbates the situation, causing physical and mental strain. The participants in focus group 1 reported that they lacked variety in their work, as they focused mainly on curative work and performing extractions. They wanted to do preventive work, but the clinics lacked the resources. Added stressors mentioned included the environment and equipment, e.g. heat in clinics, noise and lack of space. Poor organisational structure and communication in/by management, lack of support for problems and lack of personal development were also challenges reported by dental practitioners in KwaZulu-Natal. Career development in the public sector is another factor that causes stress among dental practitioners – there is no career pathway for dental staff to progress along. Postgraduate studies are not incentivised, and there are no specialist programmes within the department for dental practitioners to move on to. Career progression strategies are required in the public sector. Burnout is commonly seen in the ‘caring professions’, i.e. dentists, nurses, doctors, teachers and social workers.[10,15] In a Finnish study investigating coping strategies, the dentists felt dedicated to their work despite high job demands, emotional ‘dissonance’ and changes in the law regarding the worksite and one’s work.[10] The study found that dentists with greater control over their job tasks, and those who try to improve themselves, are best equipped to deal with job demands. Hakanen et al.[10] concluded that by improving the work environment, we can enhance dentists’ feelings of vigour and dedication through job enrichment approaches. The researchers in the present study found that dentists in the public sector perceived their dental practice as more demanding than service in private practices. More qualitative studies are needed of the psychosocial aspects of dentistry as experienced among private and public sector dentists in SA. The practitioners in this study reported experiencing muscle pain, but continued their work despite these symptoms. Some received support in this issue from management, while others did not. Their quality of life was affected: some participants had problems sleeping, or could not play with their children, and simple chores at home were a problem. Some became physically ill, and opted to change careers. Dentistry is a 5-year course, and dental therapy and oral hygiene are each 3-year courses. Preclinical and clinical training are covered in these years for all three courses, together with clinical practice and a large volume of lectures. This can be stressful for students, and although burnout is mainly seen among dental professionals, many researchers have seen it among dental students.[16]

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Acharya[17] found that the major causes of stress among newly qualified dentists and students in his study were practice-management issues, treating children, time pressure and fear of failure. Fear of facing one’s parents after failure, followed by fear of failure itself, were the greatest stressors. Stress is commonly seen in dental practitioners and undergraduates, and it is proposed that the ability to identify, perceive and manage it is an important attribute for health workers.[18] Burnout has been described as professional exhaustion,[19] and it is characterised by a loss of enthusiasm for work and a low sense of personal accomplishment.[16] Both the personal and educational environments can contribute to stress, but students perceived that workload and a sense of self-efficacy influenced burnout, as seen in a Columbian study where 7% (n=394) of students experienced burnout.[20] The participants in this study also found that students were stressed in clinics due to workloads and patient care. Clinical supervisors reported that their students were not keen to correct their posture, as they did not experience pain. There is a need for change in this attitude, or these bad habits will be carried into professional practice. Students in clinical training benefit from feedback and demonstration. In daily feedback, it would help students if posture and ergonomics, as well as the specific clinical procedures, were discussed. Demonstrations of proper posture should be included in all clinical years of training, and not just preclinical. Prevention of percutaneous injuries should also be taught and assessed throughout training as these injuries were mentioned as a cause of stress. The inclusion of occupational health and ergonomics training in dental curricula has been suggested by many studies.[21,22] Injury prevention and dental ergonomics should be taught to dental practitioners, as these skills and knowledge are required to practice in an ergonomically correct position.[21,23-25] A limitation of the present study was that it was confined to KZN, and did not cover the whole of SA. The study population does not represent all dental practitioners, but it nevertheless allowed the researcher to probe areas that could not be investigated in a cross-sectional study. Multiple focus groups were conducted to reduce bias, and the results and conclusions from all four focus groups were very similar.

Conclusion

The reported causes of stress and burnout among this cohort arose from lack of teamwork, high patient numbers, lack of job variation and poor

Research equipment. These dental practitioners incorporate exercise into their routines, seek professional help, lower patient load and share workload to cope with their professional practice. The participants recommended that clinical practice supervision should include a score for posture assessment in the daily assessment rubric. Students should also be taught to assess the arrangement of their equipment within the workplace in order to prevent harmful practice habits. Stress management techniques and workplace posture assessment should be added to the curriculum, especially in preclinical training, to make students aware of managing stress and correct working postures. A multidisciplinary approach should be used when teaching dental students about occupational health issues. Dental curricula, while overloaded in the second-last and final year, need to include occupational health safety principles and training. An interesting point that the participants raised is the lack of preventative dentistry in the public sector; while this is an issue for patient care, it also contributes to the rise in MSDs, as it means there is a lack of variation in dental work. Further research into delivery of patient care, via preventive dentistry service delivery, is required in SA. As an offshoot to this study, participants also recommended that a support group for dental practitioners be formed, as those who experienced pain stated that they felt a degree of isolation. This would create dialogue, to prevent self-isolation. It would be an opportunity to share experiences and to learn.

Acknowledgements. The authors would like to thank the participants for their valuable input. Author contributions. RM: PhD student, all literature reviews, data collection and data analysis, interpretation of the results as well as manuscript preparation and writing. SN: PhD supervisor. JvW: PhD supervisor. Funding. Department of Higher Education and Training Research Development Grant. Conflicts of interest. None.

1. Ahmad MS, Yusoff MMM, Razak IA. Stress and its relief among undergraduate dental students in Malaysia. Southeast Asian J Trop Med Public Health 2011;42(4):996-1004. 2. Alzahem AM, Van der Molen HT, Alaujan AH, De Boer BJ. Stress management in dental students: A systematic review. Adv Med Educ Pract 2014;5:167. https://doi.org/10.2147/amep.s46211 3. World Health Organization. Global strategy on occupational health for all: The way to health at work. Recommendation of the Second Meeting of the WHO Collaborating Centres in Occupational Health, 11 - 14 October 1994, Beijing, China. WHO: Geneva, 1995. http://apps.who.int/iris/handle/10665/36845 (accessed 22 August 2017). 4. Bhayat A, Madiba TK. The self-perceived sources of stress among dental students at a South African dental school and their methods of coping. S Afr Dent J 2017;72(1):6-10. 5. Choy H, Wong M. Occupational stress and burnout among Hong Kong dentists. J Dent Res 2017;23(5):480-488. https://doi.org/10.12809/hkmj166143 6. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101. https://doi. org/10.1191/1478088706qp063oa 7. Garstang SV, Stitik TP. Osteoarthritis: Epidemiology, risk factors, and pathophysiology. Am J Phys Med Rehabil 2006;85(Suppl):S2-S11. https://doi.org/10.1097/01.phm.0000245568.69434.1a 8. Rabiei M, Shakiba M, Dehgan-Shahreza H, Talebzadeh M. Musculoskeletal disorders in dentists. Intern J Occup Hyg 2015;4(1):36-40. 9. Hashim R, Al‐Ali K. Health of dentists in United Arab Emirates. Inter Dent J 2013;63(1):26-29. https://doi. org/10.1111/idj.12000 10. Hakanen JJ, Bakker AB, Demerouti E. How dentists cope with their job demands and stay engaged: The moderating role of job resources. Eur J Oral Sci 2005;113(6):479-487. https://doi.org/10.1111/j.1600-0722.2005.00250.x 11. Bhattacharya A. Costs of occupational musculoskeletal disorders (MSDs) in the United States. Int J Ind Ergon 2014;44(3):448-454. https://doi.org/10.1016/j.ergon.2014.01.008 12. Evans J, Henderson A, Johnson N. The future of education and training in dental technology: Designing a dental curriculum that facilitates teamwork across the oral health professions. Brit Dent J 2010;208(5):227-230. https://doi. org/10.1038/sj.bdj.2010.208 13. Rafeek RN, Marchan SM, Naidu RS, Carrotte PV. Perceived competency at graduation among dental alumni of the University of the West Indies. J Dent Edu 2004;68(1):81-88. 14. Csikar J, Bradley S, Williams S, Godson J, Rowbotham J. Dental therapy in the United Kingdom: Part 4. Teamwork – is it working for dental therapists? Brit Dent J 2009;207(11):529-36. https://doi.org/10.1038/sj.bdj.2009.1104 15. Leka S, Jain A. Health Impact of Psychosocial Hazards at Work: An Overview. Geneva: WHO, 2010. 16. Eren H, Huri M, Bagis N, et al. Burnout and occupational participation among Turkish dental students. Southeast Asian J Trop Med Public Health 2016;47(6):1343-1352. 17. Acharya S. Factors affecting stress among Indian dental students. J Dent Edu 2003;67(10):1140-1148. 18. Pau A, Croucher R, Sohanpal R, Muirhead V, Seymour K. Emotional intelligence and stress coping in dental undergraduates – a qualitative study. Brit Dent J 2004;197(4):205-209. https://doi.org/10.1038/sj.bdj.4811573 19. Campos JADB, Jordani PC, Zucoloto ML, Bonafé FSS, Maroco J. Burnout syndrome among dental students. Rev Bras Epidemiol 2012;15(1):155-165. 20. Mafla A, Villa‐Torres L, Polychronopoulou A, et al. Burnout prevalence and correlates amongst Colombian dental students: The STRESSCODE study. Europ J Dent Edu 2015;19(4):242-250. https://doi.org/10.1111/eje.12128 21. Yamalik N. Musculoskeletal disorders (MSDs) and dental practice Part 2. Risk factors for dentistry, magnitude of the problem, prevention, and dental ergonomics. Intern Dent J 2007;57(1):45-54. https://doi.org/10.1111/j.1875595x.2007.tb00117.x 22. Morse T, Bruneau H, Michalak-Turcotte C, et al. Musculoskeletal disorders of the neck and shoulder in dental hygienists and dental hygiene students. J Dent Hyg 2007;81(1):16. 23. Bhandari S, Bhandari R, Uppal R, Grover D. Musculoskeletal disorders in clinical dentistry and their prevention. J Orofac Res 2013;3(2):106-114. 24. Biswas R, Sachdev V, Jindal V, Ralhan S. Musculoskeletal disorders and ergonomic risk factors in dental practice. Indian J Dent Pract 2012;4(1):70-74. 25. Tezel A, Kavrut F, Tezel A, Kara C, Demir T, Rabia K. Musculoskeletal disorders in left- and right-handed Turkish dental students. Intern J Neuroscience 2005;115:255-266. https://doi.org/10.1080/00207450590519517

Accepted 21 December 2017.

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

Occupational therapy students’ use of social media for professional practice D Naidoo, PhD; P Govender, PhD; M Stead, BOT; U Mohangi, BOT; F Zulu, BOT; M Mbele, 4th-year OT student Discipline of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: D Naidoo (naidoodes@ukzn.ac.za)

Background. The use of social media for professional practice is an emerging trend for healthcare professionals; however, limited literature exists on the phenomenon. Social media usage is prevalent among students, as it is incorporated into many health professions education curricula. This poses potential ethical dilemmas. Objective. To examine the nature of social media usage and knowledge of ethical considerations by occupational therapy (OT) students for professional purposes. Methods. A quantitative, cross-sectional survey was administered to the entire cohort of OT students (N=128) enrolled at the University of KwaZuluNatal, Durban, South Africa in 2016. Data were analysed descriptively using Microsoft Excel 2013 (Microsoft, USA). Results. The most commonly used device to access social media was mobile phones, with WhatsApp and YouTube frequently used for both general and professional purposes. Uses included accessing social media for developing professional skills and knowledge, and in fulfilling academic requirements. Ethical dilemmas were evident among students, who indicated that social media ethical considerations should be incorporated into the curriculum. Conclusion. The study highlighted that most students use some form of social media as part of their professional practice, which has the potential to be used effectively to enhance learning opportunities. Future studies of a qualitative nature could shed light on students’ perceptions of social media and practical implications for practice. Afr J Health Professions Educ 2018;10(2):101-105. DOI:10.7196/AJHPE.2018.v10i2.980

Internet-based applications are changing the manner in which we communicate and circulate professional and personal information.[1] Improved connectivity and access to the internet have enabled people to instantaneously share ideas and interact with others on a global scale.[2,3] Ventola[4] highlighted the potential use of social media to foster understanding of the occupational therapy (OT) profession and to promote various health behaviours or fund-raising opportunities.[4] For the purpose of this study, social media are defined as ‘digital technologies and practices that enable people to use, create and share content, opinions, insights, experiences and perspectives, build relationships and promote discussion’.[5] This includes the use of discussion groups using messaging software, such as WhatsApp. The World Federation of Occupational Therapy (WFOT) position paper[6] on social media use highlights the role that social media can play in continuing professional development and enhancing networking within OT. The paper cites gathering information, improving practice and networking for knowledge development as examples of acceptable professional practice use of social media.[6] There is a growing trend of incorporating social media for professional purposes into health professions education. Snyman and Visser,[7] in a South African (SA) study comprising 344 dentists, established that social media are being used as a marketing tool. Pearson et al.[8] used an online survey to explore the use of social media among emergency medicine residents and faculty members at various sites.[8] Potential threats cited included ‘breaches of professionalism’, which included online disclosure of private information.[7] Variability in the usage trends of social media and concerns

about students maintaining clients’ privacy were also cited.[7] Despite this article referring to older, qualified professionals, the data highlight potential issues that may arise among students. Given the millennium students’ familiarity with social media and technology, there is concern that some of the threats mentioned (breach of professionalism, confidentiality) may be more evident. In contrast, some of the benefits of social media use included more effective communication and interaction among peers,[8] which could have potential positive implications for teaching and student support. Many universities, including the University of KwaZulu-Natal (UKZN), Durban, SA, are moving toward blended learning, which implies the need to explore how students use social media for educational purposes. The absence of literature relating to how OT students use social media during their undergraduate education, highlighted the need for greater insight into how social media can potentially be used to improve learning. Many policies and guidelines on how to use social media appropriately are still being developed,[5,9] as these have to be adapted to include recent advances in technology.[9,10] Pempek et al.[10] suggest that healthcare students and clinicians have difficulty in maintaining a professional persona in the more relaxed setting of social media. Despite the presence of definitions or descriptions for the use of social media in the literature,[6,,9,11] there is limited evidence on OT students’ views regarding ethical practice during social media use. This article aims to describe the nature of social media usage by undergraduate OT students at UKZN, emphasising the benefits of social media for professional purposes and students’ knowledge of ethical considerations when using various social media sites for professional practice.

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Research Methods

facilitated administration and collection of the questionnaires. This prevented the influence of possible power differentials. Descriptive statistics were employed to analyse the data with the use of Microsoft Excel 2013 (Microsoft, USA).

A cross-sectional survey design was employed.[12] The target population comprised all undergraduate OT students (N=128), through four levels of study, registered in 2016 in the School of Health Sciences at UKZN. A survey was designed through exploration of the current literature and consultation with a biostatistician. The questionnaire comprised four sections, i.e. (i) demo graphics (including age, gender, level of study, level of information and communication technology (ICT), knowledge and devices on which social media are accessed); (ii) social media use (type of media and frequency of use); (iii) general and professional use of social media; and (iv) ethical considerations regarding the use of social media. The questions were fixed to ensure consistency and reliability. The questionnaire was appraised by a biostatistician, supervisors of the study and a data scientist and matched against the research questions for the study to ensure face and content validity. A pilot study was completed with 34 students (mean age 19.6 years) currently enrolled in the discipline of physiotherapy at UKZN. A number of questions were revised after the pilot study to reduce ambiguity. Data were collected over 2 months. Students were invited to participate during an allocated period. The authors were not present in the session and an academic development officer

while 34% (n=36) had no such previous training and 4% (n=4) had advanced-level training. The same social media account was used for both general and professional purposes by 77% (n=82) of the students. Mobile phones (n=102; 96%), laptops (n=91; 86%) and desktop computers (n=57; 53.8%) were the most commonly used devices to access social media. Tablets were used by 50% (n=53) of the students.

Ethical approval

Ethical clearance was obtained from the Human and Social Sciences Ethics Committee (ref. no. HSS/1117/016U), including gatekeeper permission from the relevant academic leaders. Written informed consent was obtained from students prior to initiating the study. Principles of autonomy and anonymity and the right to withdraw were observed.[13] The study only explored the use of social media among OT students at UKZN. Furthermore, the survey design did not allow researchers to explore reasons for the use of social media sites.

Social media for professional use

Social media were reported to be an important aspect of students’ professional lives. Eightythree percent of 4th-year, 42% of 3rd-year, 75% of 2nd-year and 74% of 1st-year students agreed that social media are an important aspect of professional life. Fig. 1 highlights the various sites used across the four levels of study. WhatsApp, YouTube, Pinterest, Facebook and blogs were used by the majority of students for professional purposes. There were similar WhatsApp and YouTube usage trends across the years for professional use (Fig. 1). There was a greater use of blogs for professional use by 3rd-year (71%) and 4th-year (74%) students than by 1st-year (13%) and 2nd-year (22%) students. There was an increase in professional use of Pinterest from the 1st (6%) to the 4th (77%) years. Thirty-nine percent of 1st-year, 39% of 2nd-year, 47% of 3rd-year and

Results

The response rate was 83%, with 106 of the 128 questionnaires distributed returned. The sample comprised 90% females (n=95) and 10% males (n=11), with a mean age of 22.5 (range 17 - 30) years. The study included 1st-year (n=31; 29%), 2nd-year (n=34; 32%), 3rd-year (n=17;16%) and 4th-year (n=24; 23%) OT students. More than half of the students (n=62; 59%) had a school level of training in ICT,

100 90 90 87 88

88 84 84

80 70 Students using site, %

76 77

74 71 64

60 53 50 40

52 47

47 39 39 31

29 22

18 10

13 8

12 6

3 3

0 Facebook

Twitter

Instagram

Blogs

YouTube

Tumbler

Social media sites 1st

Fig. 1. Social media use for professional purposes (N=106).

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2nd

3rd

4th

Myspace

Snapchat

Discussion groups

Other

Research 64% of 4th-year students used Facebook professionally. Despite none of the 1st years using Tumbler professionally, 52% of the 4th years used this site professionally. Interestingly, 1st years (32%) used discussion groups professionally, which was more so than students in any other year. A small percentage of students (6%) used other social media for professional use, which included Flickr, Vine, Blackberry Messenger and LinkedIn (Fig. 1). Frequency of social media use for professional purposes YouTube and Pinterest had the highest frequency of daily use. Blogs, WhatsApp and Facebook were accessed for professional use at least once a day. Students in all 4 years used WhatsApp most frequently in their daily professional use, with 4th-year students having the highest frequency of use (Table 1).

None Developing skills and knowledge Promoting skills and abilities Disscussion with other professionals Providing others with advice Improving clinical practice University requirements Raise awareness about profession

Ethical considerations in social media use Interestingly, 96% of students agreed that it is important to consider ethics online when using social media professionally, with 90% agreeing that poor behaviour online can have an impact on the reputation of the profession. However, only 14% of students believed that ethical behaviour online is good. Fig. 4 illustrates studentsâ&#x20AC;&#x2122; awareness of ethics in this study. Despite 48% of students being fully aware of ethics and 42% agreeing that they have been taught about ethics in their studies, 66% believed that ethics on social media needs to be covered in lectures, especially 3rd years (77%) and 4th

5 34 Students, %

Professional uses of social media

Professional purpose of social media use Fig. 2 highlights the main purposes of social media for professional use by students in this study. These included for academic purposes (78%), developing skills and knowledge (59%), improving clinical practice (53%) and discussion with other professionals (37%).

General v. professional social media use When comparing various social media sites, it appears that students use these more often for general than professional purposes, with Facebook, Instagram and Snapchat showing the greatest difference between general and professional use (Fig. 3). Snapchat was used by 38% of students generally, whereas only 2% of students used it professionally. Discussion groups were used by 21% of students generally and by 21% professionally. Blogs were used by 44% of students generally and by 39% professionally. WhatsApp was used by 94% of students generally and by 86% professionally (Fig. 3).

78 53 28 37 22 59 0

100

Students, %

100 90 80 70 60 50 40 30 20 10 0

94 86

69 44

48 39

21 21

k oo

b ce Fa

er itt

am gr

sta

s og

t e er pp es ub bl er Bl tsA uT m nt ha Yo Tu Pi W General use

Fig. 2. Professional purpose of social media use by students (N=106).

e ac

t di

4 2

p ys

ck Fli

t ha

1 0

n sio s us up sc gro

n Vi

Professional use

Fig. 3. General v. professional uses of social media sites (N=106).

Table 1. Frequency of social media use for professional purposes (N=106) Student, year 1st

2nd

3rd

4th

Frequency Rarely

Facebook, % 16

Blogs, % 6

WhatsApp, % 0

YouTube, % 10

Pinterest, % 0

Monthly

Weekly

Daily

Rarely

Monthly

Weekly

Daily

Rarely

Monthly

Weekly

Daily

Rarely

Monthly

Weekly

Daily

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Research years (76%). Distinctively, 4th-year students (17%) reported feeling the least aware of ethics (Fig. 4).

Discussion

Disagree

14 6

Neutral

Agree

Fig. 4. Students’ awareness of ethics (N=106).

104

ca P n ub be lic us in ed for by ma an tio yo n ne

Co nt be ent ed can ite d

et Tau hi gh cs in t ab stu ou di t es Le ct ur c es m ove sho ed r s ul ia oc d et ial hi cs

100 90 80 70 60 50 40 30 20 10 0

Fu lly of awa et re hi cs

Students, %

The SA internet user population reached 20 million in 2016.[14] Gikas and Grant[15] found that 67% of 10 000 students used their mobile phones for the majority of their academic activities. Similarly, Goldstuck’s[16] SA study found that students felt that social media enhance their academic and social lives. OT students at UKZN use social media for both general and professional purposes. As noted in the literature,[17-20] WhatsApp, Facebook and Instagram were the most commonly used social media sites in this study. WhatsApp, YouTube, Facebook and Pinterest were all commonly used by the students for professional purposes. WhatsApp appears to be popular owing to the speed of communication, which includes the ability to share text messages, pictures and voice notes rapidly.[16] Mohapatra et al.[21] identified that the use of software applications, such as WhatsApp, has the potential to enhance communication in healthcare and medical education. There is evidence that students use social media for educational purposes, which corresponds with that in the current literature.[2,7,9,10] Lui et al.’s[22] systematic review highlighted that blended learning (face-toface and e-learning) has a positive effect on learning in higher education.[22] The participants noted that fulfilling university requirements, developing skills and knowledge and improving clinical practice were the main reasons for professional social media use. Gikas and Grant[15] described social media as an open environment where ideas can grow online. YouTube and Facebook have both been found to be useful sites for content sharing within academic institutions.[23] For example, Facebook has been used to start health science special interest/discussion groups, while YouTube enhances learning by providing additional content from an outsider’s perspective.[23] In our study, there was a decline in the frequency of YouTube use as students progressed to their final year. The highest frequency of usage occurred in 1st and 2nd years. This finding could be owing to 1st- and 2nd-year students still seeking foundational knowledge. Additionally, YouTube videos have been used to enhance clarification of difficult concepts, especially in subjects such as anatomy and physiology. Jaffar et al.[24] found that 98% of students used YouTube as an online information resource to enhance their understanding of human anatomy.

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Pinterest, a digital pinboard, has gained rapid popularity. WFOT acknowledged Pinterest in their position statement on social media usage.[6] Despite Pinterest mainly being used as a social tool, business and education have shown much interest in it.[21] The social and visual aspects of Pinterest make it extremely appealing to educators, as it has the potential to provide learning opportunities for students.[25] The current study noted an increase in the frequency of Pinterest use, as students progressed from 1st to final year. This could be attributed to the increase in students’ exposure to service-learning settings; hence the need to generate creative ideas when planning intervention sessions. Blogs have been used for teaching and learning purposes and to share lessons with colleagues.[2,26] In this study, the higher usage of blogs by 3rd- and 4th-year students could be accredited to these students needing to complete a blog as part of their service-learning modules. The reflective practice inherent in writing blogs serves to deepen students’ experiences during professional practice. Discussion groups appeared to be more common among 1st-year students than students in any other year. This could be because younger generations are interested in gaining knowledge from online sources. Despite the benefits gained through the use social media, there is a risk of unethical practice. Some risks include the blurring of professional and social boundaries, breaching patients’ privacy and confidentiality (especially with taking or sharing pictures or information) and damaging the public image of the profession.[27,28] Students reported that even though ethics is covered in lectures, ethics specifically focusing on social media use requires further input. Despite WFOT recently introducing a position statement on the principles of good practice when engaging in social media for professional practice,[6] ethics in social media has been largely neglected. Even the Health Professions Council of SA has not included online ethics in their ethical guidelines.[29] WFOT guidelines include the setting of a clear boundary when individuals speak for themselves and when they speak for the profession, understanding that the image presented online represents both the individual and the profession and therefore treating others on a public platform with consideration.[6] Although this position paper provides individuals in the OT profession with good social media principles, there is lack of detail as what exactly good ethical conduct online constitutes, especially around what can be shared on social media. The current cohort of OT students have been accustomed to social media use in their personal capacity (59% used social media in school) and may not be cognisant of what constitutes a breach of confidentiality or privacy with regard to patients. Ethical considerations are fundamental concepts that students must learn, as they need to be accountable for their online posts and can be legally bound to uphold standards of professional practice.[28,30] At UKZN, final-year OT students use social media to convey information to patients and their caregivers about home programmes and reflect on their practice in blogs. However, they reported feeling less aware of ethics than the 1st- and 2nd-year students, which may be attributed to 4th-year students experiencing ethical dilemmas in real-life situations during service-learning placements and feeling inadequately equipped to translate the theory they learnt during their 1st year into practice. Students need to have a wellestablished understanding of the ethical practice around social media use to prevent breaches of confidentiality or blurring of professional and personal boundaries. Chretien and Kind[31] described the inability to maintain a professional persona in the more relaxed setting of social media.

Research In Ventola’s[4] study, 68% of both practising and student physicians felt it was ethically problematic to interact with patients on social networks for either personal or professional reasons. However, 56% of patients wanted their physicians to use social media for activities such as scheduling appointments and answering general questions about their conditions.[5] This highlights the challenge of negotiating between meeting patients’ needs and following ethical guidelines. There is a need for the establishment of clear ethical guidelines from professional bodies to protect both the healthcare practitioner and patient and for health professions programmes to ensure that 2nd - 4th-year students have sufficient opportunities for lectures and discussions on social media ethics.

Conclusion

This quantitative, cross-sectional study was conducted to determine the nature of social media usage and ethical awareness among a cohort of OT students. Sites such as WhatsApp, YouTube and Facebook appeared to be more popular in this particular context. The study has highlighted the important role that social media play in many students’ professional lives, with a variety of sites being used for fulfilling university requirements and improving clinical practice. Another vital area highlighted was the challenges of ethical practice and social media use. Students appeared to have some awareness of ethical considerations. However, many students lacked awareness of policies, guidelines and legislation that relate to their online usage, thereby placing them at risk of overstepping boundaries and incurring legal implications. The authors therefore believe that social media need to be covered in ethics lectures and measures have to be put in place to ensure that policies, procedures and guidelines are adhered to. We therefore suggest that this study be used as a starting point for further studies into the extent of the benefits of social media for professional practice. Acknowledgements. The authors would like to acknowledge the participants in the study. Author contributions. DN and PG were responsible for the conceptualisation and supervision of the study, as well as for the drafting and revision of the manuscript. MS, UM, FZ and MM were involved in the execution of the study and the analysis and drafting of the manuscript. Funding. None. Conflicts of interest. None.

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Snyman L, Visser JH. The adoption of social media and social media marketing by dentists in South Africa. S Afr Dent J 2014;69(6):258-264. 8. Pearson D, Bond MC, Kegg J, et al. Evaluation of social media use by emergency medicine residents and faculty. West J Emerg Med 2015;16(5):715. https://doi.org/10.5811/westjem.2015.7.26128 9. Landman MP, Shelton J, Kauffmann RM, Dattilo JB. Guidelines for maintaining a professional compass in the era of social networking. J Surg Educ 2010;67(6):381-386. https://doi.org/10.1016/j.jsurg.2010.07.006 10. Pempek TA, Yermolayeva YA, Calvert SL. College students’ social networking experiences on Facebook. J Appl Develop Psychol 2009;30(3):227-238. https://doi.org/10.1016/j.appdev.2008.12.010 11. Wu WH, Wu YC, Chen CY, Kao HY, Lin CH, Huang SH. Review of trends from mobile learning studies: A metaanalysis. Comput Educ 2012;59(2):817-827. 12. Lavrakas PJ. Encyclopedia of Survey Research Methods. Thousand Oaks, CA: SAGE, 2008. 13. World Medical Association. Declaration of Helsinki. Ethical principles for medical research involving human subjects. 2008. http://www.wma.net/e/policy/b3.Htm (accessed 23 March 2018). 14. Goldstuck A. SA internet penetration to reach 40% in 2017. https://www.worldwideworx.com (accessed 23 March 2018). 15. Gikas J, Grant MM. Mobile computing devices in higher education: Student perspectives on learning with cell-phones, smartphones and social media. Internet High Educ 2013;1(19):18-26. https://doi.org/10.1016/j.iheduc.2013.06.002 16. Goldstuck A. SA high-tech student. 2013. https://www.worldwideworx.com/hightech-student (accessed 6 September 2017). 17. Snyman A. Social media – the latest South African stats. 2016. https://www.webafrica.co.za/blog/social-media-2/ social-media-latest-south-african-stats/ (23 September 2016). 18. Sponcil M, Gitimu P. Use of social media by college students: Relationship to communication and self-concept. J Technol Res 2013;1(4):1. 19. Verdonck MC, Ryan S. Mainstream technology as an occupational therapy tool: Technophobe or technogeek? Br J Occup Ther 2008;71(6):253-256. 20. Gilbert S. Learning in a Twitter-based community of practice: An exploration of knowledge exchange as a motivation for participation in #hcsmca. Inform Commun Soc 2016;19(9):1214-1232. https://doi.org/10.1080/ 1369118X.2016.1186715 21. Mohapatra DP, Mohapatra MM, Chittoria RK, Friji MT, Kumar SD. The scope of mobile devices in health care and medical education. Int J Adv Med Health Res 2015;2(1):3. 22. Lui Q, Peng W, Zhang F, Hu R, Li Y, Yan W. The effectiveness of blended learning in health professions: Systematic review and meta-analysis. J Med Internet Res 2016;18(1):e2. https://doi.org/10.2196/jmir.4807 23. George DR, Dellasega C. Use of social media in graduate-level medical humanities education: Two pilot studies from Penn State College of Medicine. Med Teach 2011;33(8):e429-e434. https://doi.org/10.3109/01421 59X.2011.586749 24. Jaffar AA. YouTube: An emerging tool in anatomy education. Anat Sci Educ 2012;5(3):158-164. https://doi. org/10.1002/ase.1268 25. Hansen K, Nowlan G, Winter C. Pinterest as a tool: Applications in academic libraries and higher education. Can J Libr Inform Pract Res 2012;7(2). https://doi.org/10.21083/partnership.v7i2.2011 26. Cain J, Scott DR, Tiemeier AM, Akers P, Metzger AH. Social media use by pharmacy faculty: Student friending, e-professionalism, and professional use. Curr Pharm Teach Learn 2013;5:2-8. 27. Nyangeni T, du Rand S, van Rooyen D. Perceptions of nursing students regrading responsible use of social media in Eastern Cape. Curatonis 2015;38(2). https://doi.org/10.4102/curationis.v38i2.1496 28. Grobler C, Dhai A. Social media in healthcare context: Ethical challenges and recommendations. S Afr J Bioethics Law 2016;9(1):22-25. https://doi.org/10.7196/SAJBL.2016.v9i1.464 29. Health Professions Council of South Africa. Guidelines for good practice in the healthcare professions: General ethical guidelines for the healthcare professions. http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/ conduct_ethics/Booklet%201.pdf (accessed 8 March 2016). 30. Helm J. Ethical and legal issues related to blogging and social media. J Acad Nutr Diet 2013;113(5):688-690. 31. Chretien KC, Kind T. Social media and clinical care. Circulation 2013;127(13):1413-1421. https://doi.org/10.1161/ CIRCULATIONAHA.112.128017

Accepted 12 October 2017.

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Research

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

Establishing consensus among interprofessional faculty on a genderbased violence curriculum in medical schools in Nigeria: A Delphi study O I Fawole,1 MBBS, MSc, FNMC (PH), FWACP; J van Wyk,2 PhD; A A Adejimi,3 MBBS, MPH, FWACP; O J Akinsola,4 BSc, MSc, MPhil; O Balogun,5 MBBS, MPH Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria Department of Clinical and Professional Practice, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 3 Department of Community Medicine, College of Medicine, Ladoke Akintola University of Technology, Osogbo, Nigeria 4 Department of Community Medicine and Primary Health Care, College of Medicine, University of Lagos, Nigeria 5 Department of Community Medicine, College of Medicine, University of Ibadan, Nigeria 1 2

Corresponding author: O I Fawole (fawoleo@ymail.com)

Background. Gender-based violence (GBV), as a topic of medical study and practice, is an integral component of medical education in many developed countries. There is an increasing need to equip medical practitioners with appropriate knowledge, attitudes and skills to care for victims of GBV. Objectives. To obtain consensus among stakeholders on content, the members of faculty who should teach the subject and the methods of training relating to GBV curricula in three medical schools in south-west Nigeria. Methods. Three rounds of the Delphi technique involving 52 experts from among academics, medical practitioners, government and non-governmental organisations were conducted. The first round (RD 1) was open-ended, while subsequent rounds were structured. Consensus was defined as a gathering around mean (>3.5) responses with minimal divergence (standard deviation (SD) <1.5) to the RD 2 questionnaire; strong consensus was >4.0. For the RD 3, consensus was regarded as >50% satisfaction with the rankings from RD 2. A strong consensus was taken as >60% satisfaction. Results. Themes identified in RD 1 were: reasons for teaching GBV; teaching methods, strategies needed and departments best positioned to teach it; professions to involve in training; academic level to offer training; and strategies to assess effective training. From RD 2, the topics ranked highest for inclusion in training were (mean (SD)): complications of GBV, 4.44 (0.63); and safety plan, 4.44 (0.51). Offering training to final-year medical students was most preferred, at 4.25 (1.13); for teaching methods, using videos for training, at 4.63 (0.89), was ranked highest, followed by information, education and communication materials, at 4.50 (0.82). Discussion with victims ranked highest as the most preferred format for teaching, followed by didactic lectures, at 4.06 (0.93) and 4.00 (0.89), respectively. The departments selected to teach GBV were Public Health, at 4.19 (0.91); Accidents and Emergency, 4.06 (0.85); Family Medicine, 3.81 (1.05); and Obstetrics and Gynaecology, 3.81 (0.89). Other professionals suggested were psychologists, social workers and lawyers. With regards to assessment, written examination ranked highest, at 4.06 (0.85). RD 3 confirmed the rankings of RD 2 on all themes, and sought additional suggestions for the training. Most (82.9%) respondents had no additional suggestions; the few elicited included clarifying cultural misconceptions around GBV, involving religious leaders and psychologists, and the recommendation that the teaching should be sustained. Conclusion. These results will inform the development of evidence-based competencies relevant to healthcare providers in the African context. The need for periodic review of the curricula of medical schools to ensure that they address patient and societal needs is highlighted. Afr J Health Professions Educ 2018;10(2):106-113. DOI:10.7196/AJHPE.2018.v10i2.988

There is growing international consensus that health services need to respond to the needs of those experiencing abuse.[1] There is also an increasing recognition of the need to equip medical practitioners with the appropriate knowledge, attitudes and skills to care for victims of intimate partner violence (IPV). Concerns have been raised that faculty possibly neglect teaching of the topic, as it is not included in medical curricula.[2] It is therefore imperative to address this shortcoming in medical curricula, especially in low-income countries where traditions have supported and condoned levels of IPV.[3] Different specialised groups of physicians are needed to care for women who have experienced IPV, when managing complications linked to abuse.[3] Education about gender-based violence (GBV) in general offers a logical solution in addressing the problem of ignorance.[4] Education about violence has been integrated into medical schools, and is being taught by a variety of faculty in many high-income countries.[5,6] Evaluations show that training on GBV and IPV generally improves the knowledge, attitudes and skills of students and clinicians.[4] However, medical faculty in many middle- and low-income

countries are apprehensive about the complexities of addressing the topic. Apart from concerns over content and training methods, there is also a lack of agreement on the faculty best positioned to offer such training.[7,8] Therefore these issues need consideration, to prepare a range of medical faculty to teach, serve and practise effectively in this area. The present study was conducted to obtain consensus among interprofessional stakeholders on the content, methods and faculty to involve in educating and training medical students on GBV in south-west Nigeria. The study also explored reasons why stakeholders thought the teaching was necessary; it identified the stage in the curriculum best suited to teach the topic, and how to assess the effectiveness of training.

Methods

Study design

The Delphi technique[9] was used to obtain consensus among experts on issues relating to the design of a GBV curriculum. Three rounds

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Research of questionnaires were circulated. The first round (RD 1) used openended questions; the next two rounds (RD 2 and 3) were structured. The responses from each round were summarised and reported to the stakeholders, who were then given an opportunity to respond in the subsequent round. The questions in RD 1 asked whether GBV should be included in the curriculum. The questionnaire also explored the potential content and methods to be used, and asked experts about their previous training. The focus of RD 2 was to consolidate and validate suggestions on the content and methods generated by the RD 1 questionnaire. Stakeholders prioritised their responses by ranking each suggestion according to importance.

Study setting

The study was conducted in Lagos, Oyo and Osun states of south-west Nigeria in the medical schools of the University of Ibadan, the University of Lagos and the Ladoke Akintola University of Technology. In addition, relevant officials from the Ministries of Health and Women Affairs in the three states were invited as stakeholders. The three universities are public institutions, and all are affiliated to a teaching hospital.

Selection of expert panel

An expert was defined as a person with relevant knowledge of and experience in teaching about issues relating to GBV, with experience regarded as useful to inform the education of medical students. Four categories of experts were identified, and one academic, two medical practitioners, three government officials and four representatives of non-governmental organisations were included in the study.

The research team of two academic researchers and three medical practitioners, all familiar with issues relating to GBV in Nigeria, generated a list of nominees. They brainstormed and identified the most appropriate disciplines, organisations and literature to be used in identifying the categories of experts.[3,10]

Invitation of experts

Experts were contacted by telephone or in person and invited to participate. A detailed information sheet explaining the study purpose and procedures, including the level of commitment required, accompanied the RD 1 questionnaire. The participants were asked to complete and return the questionnaire within 5 days, but some had to be reminded repeatedly.

Seeking consensus

Consensus was defined as a gathering around mean responses with minimal divergence, which was taken as a mean score >3.5, with a standard deviation of 1.5 or less, and consensus issues were included in the RD2 questionnaire. Very strong consensus was set at a mean >4.0. For the RD 3 questionnaire, consensus was regarded as >50% satisfaction with the rankings from RD 2. A strong consensus was taken as 60% satisfaction with results from RD2, and very strong as >70%.

Sample size

The target was to obtain responses from 10 - 20 health professional experts from each site. A total of 52 experts participated in RD 1, 51 in RD 2 and 47 in RD 3 (Table 1).

Table 1. Sociodemographic characteristics of participants Variable Medical school Ibadan Lagos Osogbo Age (years) 20 - 29 30 - 39 40 - 49 50 - 59 Sex Male Female Organisation Academics/practitioners Ministry of Health/Women Affairs Non-governmental organisation Medical specialty Accidents and emergency Dental surgery Family medicine Obstetrics and gynaecology Paediatrics Public health/ community medicine Psychiatry Other* *Ophthalmology, pathology, internal medicine, surgery.

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RD 1 (N=52), n (%)

RD 2 (N=51), n (%)

11 (21.2) 14 (26.9) 27 (51.9)

RD 3 (N=47), n (%)

11 (21.5) 14 (27.5) 26 (51.0)

10 (21.3) 10 (21.3) 27 (57.4)

1 (2.0) 18 (35.3) 27 (52.9) 5 (9.8)

1 (2.1) 14 (29.8) 23 (48.9) 9 (19.2)

23 (45.1) 28 (52.9)

2 (44.7) 26 (55.3)

42 (82.4) 5 (9.8) 4 (7.8) (n=47) 5 (10.6) 3 (6.4) 5 (10.6) 8 (17.0) 4 (8.5) 11 (23.4) 3 (6.4) 8 (17.1)

41 (87.2) 4 (8.5) 2 (4.3) (n=47 ) 4 (8.5) 3 (6.4) 5 (10.6) 7 (14.9) 2 (4.3) 6 (12.8) 4 (8.5) 16 (34.0)

1 (2.0) 15 (28.8) 28 (53.8) 8 (15.4)

22 (42.3) 30 (57.7)

42 (80.8) 6 (11.5) 4 (7.7) (n=48) 4 (8.3) 3 (6.3) 5 (10.4) 7 (14.6) 4 (8.3) 12 (25.0) 3 (6.3) 10 (20.8)

Research Questionnaire development

RD 1: The RD 1 questionnaire was developed after an extensive literature review[5-11] based on the results of our previous study with medical students and faculty in one of the institutions.[2] The questionnaire consisted of 11 items, and was open-ended. It solicited information on reasons why courses on GBV issues should be taught (Table 2); the academic level at which they should be taught; the content to be covered (Table 3); teaching methods and strategies; contact hours; duration; format; which medical department(s) should do the teaching; other health professionals to involve in teaching; and suitable teaching platforms to explore. The experts were also asked if they had prior experience in teaching and/or managing patients/victims of GBV, and whether they would share their material. RD 2: The RD 2 questionnaire was developed after analysis of the RD 1 results. The RD 2 questionnaire ranked the 12 themes identified from the

RD 1 questionnaire on a 5-point scale, in order of importance, from 5 as most important to 1 as least important. The themes were summarised as follows: the reasons why GBV issues should be taught; medical/clinical and other professionals to include in the training; content and teaching strategies to use; and the academic levels at which to offer training. The results of the ranking are shown in Table 4. RD 3: The RD 3 questionnaire informed participants of the results received on each variable of the 12 themes in RD 2. Stakeholders were asked to comment on the results, and to suggest additional items that they might not have considered initially, and/or make changes to earlier responses.

Data collection

Data collection was preceded by telephone calls to the experts by the principal investigator; next, a member of the research team made physical visits to the

Table 2. Reasons for GBV issues to be taught at medical schools Area of concern Students

Quote ‘To prepare them to recognise and handle GBV cases.’ ‘To empower them to recognise potential victims.’ ‘To create awareness of GBV among medical students.’

GBV as a problem

‘To promote enlightenment for prevention of GBV.’

Community

‘It makes them know what constitutes GBV as some of them perpetrate without knowing.’ ‘Most people don’t really know what GBV is.’

Victims

‘It’s the paradigm shift all over the world, it will ensure a better nation.’ ‘To break [the] culture of silence on the issue. Silence by female victims [is] common.’ ‘They will be able to do some counselling of the victims.’

Participant characteristics 40 - 49 years, male, Lagos, community medicine, 0 - 9 YWE 50 - 50 years, male, Ibadan, O&G, consultant/lecturer, ≥20 YWE 40 - 49 years, male, Lagos, ophthalmology, senior lecturer, 10 - 19 YWE 40 - 49 years, male, Ibadan, family medicine, consultant, 10 - 19 YWE 40 - 49 years, male, Lagos, public health, consultant/lecturer, 10 19 YWE 20 - 29 years, female, Lagos, accidents and emergency, medical officer, 0 - 9 YWE 30 - 39 years, female, Osogbo, dentist, dental officer, 0 - 9 YWE 30 - 39 years, female, Osogbo, Ministry of Women Affairs, gender officer, 0 - 9 YWE 40 - 49 years, male, Lagos, family medicine, consultant, ≥20 YWE

GBV = gender-based violence; O&G = obstetrics and gynaecology; YWE = years of work experience.

Table 3. Topics to include in a GBV training programme Topic ‘Epidemiology of GBV; identification and understanding signs of GBV’ ‘Causes of GBV; types of GBV; medico-legal view of GBV’ ‘Types of GBV; prevalence of GBV; identification of victims of GBV’ ‘Risk factors, causes, management of GBV and the local and national laws on GBV’ ‘GBV and culture; societal responsibilities to GBV victims' ‘Female genital cutting and widow inheritance’ ‘Ethics of managing GBV and policy issues around GBV’ ‘Measurement issues in GBV’ ‘Understanding the mind of perpetrators, including forensics and jurisprudence of GBV’

Participant characteristics 40 - 49 years, female, Lagos, community medicine, senior lecturer, 0 - 9 YWE 40 - 49 years, male, Ibadan, family medicine, consultant, >20 YWE 50 - 59 years, female, Ibadan, community medicine, senior lecturer, 10 - 19 YWE 40 - 49 years, female, Osogbo, paediatrics, consultant, 10 - 19 YWE 40 - 49 YWE, female, Osogbo, family medicine, consultant/ lecturer, 0 - 9 YWE 20 - 29 years, female, Lagos, paediatrician, consultant, 0 - 9 YWE 50 - 59 years, male, Ibadan, community medicine, lecturer/ public health physician, 10 - 19 YWE 50 - 59 years, male, Lagos, O&G, senior lecturer, 10 - 19 YWE 40 - 49 years, male, Ibadan, oral pathology, lecturer/ consultant, 10 - 19 YWE

GBV = gender-based violence; YWE = years of work experience; O&G = obstetrics and gynaecology.

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Research Table 4. Ranking of categories for the training curriculum by participants Categories Reasons why GBV should be taught Content of GBV training for the students

Strategies for teaching GBV

Responses received Awareness of GBV Prevention and control Support or counsel victims Refer to where to seek help Identify/screen GBV cases Preparedness to treat GBV cases Prevention and safety Complications Medical/legal aspect of violence Signs and symptoms Role of physicians in GBV control Risk factors of GBV Causes of GBV Types of GBV Ethical issues, e.g. confidentiality etc. Management of victims Gender equality Definition of GBV Prevalence/epidemiology Identification of victims Video – documentaries, clips IEC material – posters, flyers, charts PowerPoint presentation Web-based/internet Skills training Case-based learning Role play Didactic lectures

Mean (SD) 4.56 (0.63) 4.44 (0.81) 4.44 (0.81) 4.44 (0.81) 4.19 (1.05) 4.13 (1.09) 4.44 (0.51) 4.44 ( 0.63) 4.38 ( 0.60) 4.38 (0.72) 4.38 (0.80) 4.31 (0.70) 4.31 (0.79) 4.31 (0.95) 4.25 (0.93) 4.19 (0.66) 4.19 (1.17) 4.13 (0.89) 4.13 (0.19) 4.13 (1.03) 4.63 (0.89) 4.50 (0.82) 4.19 (0.98) 4.06 (0.85) 3.94 (0.93) 3.94 (1.06) 3.75 (1.13) 3.75 (1.54)

600 500 400 300 200 100 Longitudinal Periodic Once

4.25 (1.13) 3.88 (1.09) 3.44 (1.03) 3.13 (1.26) 2.69 (1.54) 2.69 (1.54) 3.88 (1.26) 3.81 ( 1.17) 2.19 ( 1.22)

4 hours 2 hours >4 hours Discussion with victims Didactic lectures Bedside teaching Case study/presentation report Community medicine Accidents and emergency Public health

3.25 (1.4) 3.19 (1.8) 2.94 (1.6) 4.06 ( 0.89) 4.00 ( 0.93) 3.69 ( 1.49) 3.88 ( 1.26) 4.19 (0.91) 4.06 ( 0.85) 4.06 ( 0.93)

Level/year GBV should be taught

Duration of GBV training Contact hours

Formats for teaching Departments well positioned to teach

continued...

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Research Table 4. (continued) Ranking of categories for the training curriculum by participants Categories Other professionals who can teach Why other professionals should teach

Responses received Obstetrics and gynaecology Family medicine Psychiatry Dentistry Psychologist Social worker Nurse Lawyer Counsellor Sociologist Paediatrician

Mean (SD) 3.81 ( 0.89) 3.81 (1.05) 3.56 (1.21) 3.19 (1.42) 4.19 (0.98) 4.13 (1.02) 3.94 (0.99) 3.81 (0.83) 3.81 (1.11) 3.81 (1.11) 3.44 (1.41)

Multidisciplinary Intersectoral Social problem

4.38 (0.81) 4.31 (0.79) 4.23 ( 0.86)

Hospital Community Classroom

4.38 (0.95) 4.38 (0.96) 4.31 (0.79)

Written examination Term paper (assignment) Oral examination Clinical examination

4.06 (0.85) 3.75 (1.07) 3.63 (1.03) 3.56 (0.89)

Venue to teach GBV

Assessment methods on GBV GBV = gender-based violence; IEC = information, education and communication.

experts to distribute the information sheet and questionnaire. The study instruments and information sheets were pretested on five resident doctors from the University College Hospital, Ibadan, and necessary adjustments were made before data collection commenced. The Delphi questionnaires were hand-delivered to participants, and collected a few days later by a research assistant. Each round was accompanied by an information sheet, which in RD 1 introduced and explained the study to respondents under the following subheadings: What is a Delphi study? What is the purpose of the study? Why have I been invited to take part? What will I be asked to do if I take part? Who is organising the research? How will confidentiality be maintained? What do I do now? How do I contact the principal investigator? The information sheet used in RD 2 provided feedback on the results of the previous RD, and it was modified to suit RD 3 of the study. RD 1 data collection occurred between June and July 2016. The RD 1 questionnaire took approximately 30 minutes to complete. RD 2 data collection took place between August and October 2016, while RD 3 commenced in November 2016 and ended in January 2017. RD 2 took about 15 minutes to complete, and RD 3, 20 minutes. The data collection was conducted by three trained resident doctors, who were assisted with retrieval of the completed questionnaires by a research assistant.

Data analysis

The three rounds were analysed using different methods. RD 1: The data generated from the open-ended questions in RD 1 were coded. Data were entered into Statistical Package for Social Sciences (SPSS;

IBM Corp., USA) version 16 and analysed using Excel (Microsoft, USA). These open-ended, qualitative data were coded and categorised in response to each research question. RD 2: The data were entered and analysed using SPSS version 16. Means and standard deviations (SDs) were calculated for all responses. Each mean was used to obtain a numerical indication of the overall support for a statement, where the responses to the statements were measured on a scale from 1 (least important) to 5 (most important). Mean values between 2 and 3 were interpreted as uncertainty or indicating no consensus, while >3.5 and <1 indicated clear positive and negative consensus, respectively. The SD provided a measure of the dispersion of the responses. A small SD between 0.1 and 1.5 was interpreted as indicating greater certainty and consensus on the item being measured. RD 3: The data obtained were coded and entered into SPSS version 16, and analysed using Excel. Respondents’ level of satisfaction with the results generated was described in percentages, while quotes on suggestions were collected.

Ethical considerations

The study was a low-risk project; however, ethical clearance was obtained from the Ethical Review Committee of the Oyo State Ministry of Health (ref. no. AD13/479/165) and the University College Hospital Institutional Review Board (ref. no. UI/EC/15/03/11). The purpose of the study was explained to participants, and verbal informed consent obtained. Stakeholders were assured of confidentiality and anonymity, and identifying details were not recorded on the questionnaires. Responses were kept confidential. The

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Research completed questionnaires were kept in a secure compartment in the custody of the main investigator. The investigators had no conflict of interest and the results did not influence their work in any way. Data were entered into a password-protected computer.

Results

Round 1 results

Sociodemographic characteristics of experts A total of 52 expert participants participated in RD 1. A little over half (53.8%) of the experts were between 40 and 49 years of age. There was a slight female preponderance (57.7%). Most (80.8%) participants were from a university or hospital, while the others represented government ministries and non- governmental organisations. The medical specialties of those from training institutions cut across 11 disciplines, including preventive medicine (25.0%), obstetrics and gynaecology (14.6%), paediatrics (8.3%) and accident and emergency (8.3%). Regarding years of work experience, 44.2% had worked for between 10 and 19 years (Table 1). Categories generated In response to RD 1, eight categories were identified for teaching about GBV issues. These were regrouped into five categories (A - E). A. Reasons why GBV issues should be taught at medical schools: Stakeholders gave reasons why GBV should be included in the medical undergraduate curriculum. The responses, as illustrated by the quotes in Table 2, focused mainly on four areas of concern, namely preparedness of students, the effect of GBV on health, and its effects on the community and on the victims. Concern was expressed that students should become knowledgeable and skilled. There was also concern to improve awareness of GBV as a public health problem, as it was believed that its inclusion in medical curricula would reduce its prevalence in the community, and providing training to students would improve the protection and treatment for victims. B. Teaching methods, strategies/resources needed and department best positioned: B1. Topics to include in a GBV training programme: Stakeholders proposed several topics to include in the curriculum, namely causes of GBV, signs and symptoms, complications, types of GBV, and management of GBV cases (Table 3). Some experts proposed the inclusion of contemporary and culture-specific topics. B2. Teaching strategies for GBV: The strategies identified as most useful included didactic lectures, seminar/small group discussions, case studies, students’ presentations of group work and student-driven research projects on GBV. According to some participants: ‘Didactic lectures, discussion format, group work for presentation and research’ (30 - 39 years, female, lecturer/public health physician, Lagos: 10 - 19 YWE) ‘Topics can be incorporated into core lectures, followed by case studies and group discussions, clinical clue ship, observer ship, and term paper/ essay’ (40 - 49 years, female, emergency medicine, consultant physician, Ibadan, 10 - 19 YWE) B3. Format for teaching: Stakeholders suggested using didactic lectures, supplemented by video documentaries, information, education and communication materials and case studies, as a possible teaching format:

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‘ Didactic lectures, true cases, case studies, skills training’ (40 - 49 years, female, clinical pathology, consultant pathologist, Ibadan, 0 - 9 YWE) ‘Didactic lectures, true cases, case studies’ (30 - 39 years, male, obstetrics and gynaecology, senior registrar, Osogbo, 0 - 9 YWE). C. Teachers: C1. Other professionals who can teach on GBV: Apart from medical practitioners, other professionals suggested who could teach on GBV included psychologists, sociologists, lawyers, nurses and social workers. For example, some participants suggested: ‘Psychologist’ (30 - 39 years, female, internal medicine, consultant physician, Lagos, 10 - 19 YWE) ‘Sociologist’ (40 - 49 years, male, community health, senior lecturer, Lagos, 10 - 19 YWE) ‘Social workers’ (30 - 39 years, female, dental surgery, dental officer, Osogbo, 0 - 9 YWE). C2. Reasons why other professionals should teach GBV: The experts motivated for teaching by other health professionals, describing GBV as a social, multidisciplinary and multidimensional problem. According to these stakeholders: ‘There are various aspects to GBV, it requires multidisciplinary approach’ (40 - 49 years, male, oral pathology, lecturer/consultant, Ibadan, 10 - 19 YWE) ‘GBV is a social problem that needs to be tackled by all’ (30 - 39 years, female, Women Department official, gender officer, Osogbo, 0 - 9 YWE) C3. Previous teaching experience on GBV Ten experts (19.2%) had prior teaching experience in GBV and had taught medical students on managing patients/victims of GBV. Seven (70%) of these experts were willing to share their materials with other teachers. D. Academic level(s) of medical students to whom training should be offered, and number of contact hours suggested by experts: The experts had various suggestions on year of schooling. These included: ‘Clinical years’ (30 - 39 years, female, consultant, obstetrics and gynaecology, Osogbo, 10 - 19 YWE) ‘400 - 600 levels’ (30 - 39 years, male, senior registrar, psychiatry, Lagos, 1 - 9 YWE) On the number of contact hours, one participant (40 - 49 years, female, community health, lecturer I, Lagos, 10 - 19 YWE) suggested two, while another (40 - 49 years, male, Institute of Child Health, senior research fellow, Ibadan, 0 - 9 YWE) suggested four. E. Strategies to assess the impact and effectiveness of the training: Written examinations were recommended by one participant (40 - 49 years, female, clinical pathology, consultant, Lagos, 0 - 9 YWE), while another (60 years, male, surgery, senior lecturer, Lagos, 10 - 19 YWE) suggested clinical examination.

Round 2 results

The highest-ranked reason for implementing teaching on GBV (4.56 (0.63)) was to increase awareness. Additional reasons selected were to provide support to victims; to prevent and control violence; and to appropriately

Research refer patients for care (4.44 (0.81 each)). As shown in Table 4, the 14 suggested topics for content of the GBV programme all ranked above 4.00. The highest-ranked topics were complications of GBV (4.44 (0.63)) and safety plans (4.44 (0.51)), and the least the definition (4.13 (0.89)), prevalence (4.13 (0.19)) and identification of victims (4.13 (1.03)). Stakeholders preferred training to be offered to the most mature students, i.e. at final-year level (4.25 (1.13)). The preferred teaching strategies included videos (documentaries and clips; 4.63(0.89)) and the use of information, education and communication materials (4.50 (0.82)). Allocating 4 contact hours to teaching was the most preferred option (3.25 (1.4)) among the experts. A longitudinal training programme was preferred over once-off training (3.88 (1.26) v. 2.19 (1.22)). The experts ranked discussions with victims as the most preferred strategy, followed by didactic lectures and case studies (4.06 (0.93), 4.00 (0.89) and 3.88 (1.26), respectively (Table 4). The medical departments considered best positioned to teach GBV were those dealing with community medicine (4.19 (0.91)), public health (4.06 (0.93)), accidents and emergency (4.06 (0.85)), family medicine (3.81 (1.05)), obstetrics and gynaecology (3.81 (0.89)), and psychiatry (3.56 (1.21)). Dentistry was the least preferred (3.19 (1.42)). The multidimensional nature of GBV was the main reason (4.38 (0.81)) for including other professionals in the teaching, followed by ‘it is a social problem’ (4.23 (0.86)). Other professionals identified included psychologists (4.19 (0.98)), social workers (4.13 (1.02)) and nurses (3.94 (0.99)). Teaching platforms included hospitals (wards and clinics, 4.38 (0.96)), community (4.38 (0.96)) and classrooms (4.31 (0.79)). A written examination ranked highest (4.06 (0.85)) as the preferred method to assess students’ learning on GBV.

Round 3 results

Most (>60%, depending on the theme) stakeholders were satisfied with the rankings from RD 2. There was consensus (Table 5) on the strategies for teaching on GBV (83.0%) and reasons why it should be taught (89.3%). Most disagreement related to the ‘format’ (23.4%), ‘venue’ for teaching (23.4%) and the ‘duration of the training’ (34.0%). The comments were, however, positive and affirmed a need for continuous and synchronised training, rather than irregular sessions, with preference shown for 2 contact hours per module. The Department of Public Health was indicated as being the best positioned to offer a course (Table 5).

The majority of all the stakeholders (82.9%) offered no suggestions on how to improve training on GBV. However, some respondents suggested clarifying cultural misconceptions around GBV (4.3%); the involvement of religious leaders (4.3%) and psychologists in teaching (2.1%); using midand end-of-term assessments (2.1%); and that training should be sustained (4.3%).

Discussion

This study was conducted to obtain consensus among stakeholders on the necessary content and teaching methods for a GBV curriculum at 3 medical schools in Nigeria. Most of the experts surveyed, representing the 3 states, were based at training institutions. However, they represented various disciplines, indicating some consensus on the multidisciplinary nature of the problem and interdisciplinary dimensions needed to address IPV as a curricular topic. Only a few participants represented the relevant government ministries and non-governmental organisations. This is not surprising, as GBV has only recently started to receive government attention in Nigeria, despite the country having been a signatory to international treaties and declarations on women’s rights for more than a decade.[12] IPV in particular in many low- and middle-income countries is often shrouded in secrecy, which inhibits victims from open discussions of abuse.[13] Most of the reasons for introducing GBV into the medical curriculum centred on students’ training needs, and an awareness of the need to address the issue in the community and to help victims of GBV. The benefit of improved awareness created by training on GBV was highly favoured. Participants preferred a structured curriculum for its ability to provide evidence-based and scientific information,[14] which is more likely to be factual, comprehensive and acceptable to healthcare practitioners and students.[15] Training on the prevention and complications of GBV were considered important, to enable students, as practitioners, to identify and manage victims appropriately. Training on the signs and symptoms of GBV, with the appropriate knowledge and skills to identify victims, was also considered important. Several instruments are used by healthcare providers to identify victims of GBV in healthcare settings. The instruments target different categories of victims, such as women, men, pregnant women or women attending special clinics, and paediatric patients. The instruments also cater for self-reporting, while clinician-administered or computer-based instruments are also used.[16] Stand-alone didactic lectures were not the most

Table 5. Consensus on content and methods of a GBV curriculum Theme Reason why GBV should be taught Strategies for teaching GBV Content of GBV training for student Other professionals who can teach GBV Level/year GBV should be taught Format for teaching Reasons other professionals should teach GBV Venue to teach GBV How training should be assessed Department in best position to teach Contact hours Duration of GBV training

Satisfied with ranking, frequency (%) 42 (89.3) 39 (83.0) 37 (78.7) 32 (68.1) 30 (63.8) 30 (63.8) 31 (66.0) 31 (66.0) 29 (61.7) 28 (59.6) 24 (51.1) 22 (46.8)

Gave some other options, frequency (%) 1 (2.1) 2 (4.3) 4 (8.5) 5 (10.6) 11 (23.4) 6 (12.8) 7 (14.9) 5 (10.6) 9 (19.1) 11 (23.4) 15 (31.9) 16 (34.0)

No response, frequency (%) 4 (8.5) 6 (12.8) 6 (12.8) 10 (21.3) 6 (12.8) 11 (23.4) 9 (19.1) 11 (23.4) 9 (19.1) 8 (17.0) 8 (17.0) 9 (19.2)

Total, frequency (%) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0) 47 (100.0)

GBV = gender-based violence.

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Research preferred format for training, but the experts in our study recognised their value in complementing visual materials to enhance learning, as has been reported in a previous study.[17] The experts did not reach a clear consensus on the duration of training necessary, possibly owing to the varying lengths of medical degrees at the three medical schools, and the variable ability to accommodate curricular additions.[1] It is also possible that experts differ across the disciplines on the number of hours necessary to dedicate to the topic, and that these decisions require further discussions before the start of a programme. There was strong consensus and agreement on the departments that should offer the training. The departments of community medicine and public health were preferred, suggesting a recognition of GBV as a major public health concern.[18] The department of accidents and emergency was preferred over obstetrics and gynaecology, which is surprising considering that GBV can result in a number of reproductive health complications in women. Studies have been conducted on GBV among physicians in both these specialties.[19,20] Many stakeholders appreciated the emotional problems that may arise following an episode of violence, and recommended the inclusion of a psychologist on the training team. Mental health complications following abuse, including anxiety disorders, depression, low self-esteem, posttraumatic stress and substance abuse have been reported previously.[21,22] Stakeholders considered the social constructs surrounding GBV, and the need for practical safety plans for victims and their children, including support from social services. Involving social-work practice in student training on GBV would provide comprehensive services to promote women’s health and safety, and to foster social principles of meeting clients at their points of need.[23 As found in our study, prior studies have also identified the teaching role of nurses. Tuft et al.[24] similarly recommended the training of nurses as educators on GBV, while legal practitioners can advise on laws to protect victims.[25] Assessment is crucial, as it drives learning,[26] and the training institutions agreed that they needed further in-house deliberations on the best assessment practices, for consideration at each university. The strength of this study lies in the use of the Delphi technique, which allows for repeated iterations on the content and format with the experts. The main limitations related to the fact that most experts represented academia, and to the attrition in later rounds. Despite attempts, few experts were available to participate from government and non-governmental organisations, owing to industrial action in two states at the time of study. Secondly, there was no response or consensus to some themes presented in RD 3, which could be viewed as indicating either satisfaction with or a lack of interest in the theme. Despite this shortcoming, the results still provide information useful for the development of a curriculum on GBV in the medical schools. It may also be possible to generalise the findings to other medical schools in Nigeria. It is recommended that an interdisciplinary and transdisciplinary approach be followed, to design a GBV curriculum to address issues relating to GBV in medical schools in the region.

Conclusion

Consensus was reached on the content, methods and faculty necessary for training medical students on GBV in south-west Nigeria. There was

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agreement on the disciplines best suited to teach such a programme, and the need to assess the training. Further discussions are needed per institution on the appropriate contact hours, duration of training and particular disciplines to involve in the training. The results will inform the development of evidencebased competencies relevant to healthcare providers in the African context. Acknowledgements. We thank the GBV experts for their time and responses. Author contributions. Conception and design: OIF, JvW; administrative support: OIF; data collection: BOB, AA, OJA; data analysis and interpretation: OIF, JvW; manuscript writing: OIF, JVW. All authors read and approved the final manuscript. Funding. Data collection was funded by the University of KwaZulu-Natal, Durban, South Africa. Conflicts of interest. None. 1. World Health Organization. Responding to Intimate Partner Violence and Sexual Violence against Women: WHO Clinical and Policy Guidelines. Geneva: WHO, 2013. 2. Fawole OI, van Wyk J, Adejimi A. Training needs on violence against women in the medical curriculum at the University of Ibadan, Nigeria. Afr J Health Professions Educ 2013;5(2):75-79. https://doi.org/10.7196/AJHPE.222 3. Mork T, Andersen PT, Taket A. Barriers among Danish women and general practitioners to raising the issue of intimate partner violence in general practice: A qualitative study. BMC Women’s Health 2014;14:74. https://doi. org/10.1186/1472-6874-14-74 4. Hamberger LK. Preparing the next generation of physicians: Medical school and residency-based intimate partner violence curriculum and evaluation. TVA 2007;8(2):214-225. https://doi.org/10.1177/1524838007301163 5. Connor PD, Nouer SS, Mackey SN, Banet MS, Tipton NG. Intimate partner violence education for medical students: Toward a comprehensive curriculum revision. South Med J 2012;105(4):211-215. https://doi. org/10.1097/SMJ.0b013e31824f8b01 6. Hussain N, Sprague S, Madden K, Hussain FN, Pindiprolu B, Bhandari M. A comparison of the types of screening tool administration methods used for the detection of intimate partner violence: A systematic review and metaanalysis. Trauma Violence Abuse 2015;16(1):60-69. https://doi.org/10.1177/1524838013515759 7. Hossain N, Khan S. Domestic abuse and the duties of physicians: A case report. Indian J Med Ethics 2015;12(4):248-250. https://doi.org/10.20529/IJME.2015.066 8. Kamimura A, Al-Obaydi S, Nguyen H, et al. Intimate partner violence education for medical students in the USA, Vietnam and China. Public Health 2015;129(11):1452-1458. https://doi.org/10.1016/j.puhe.2015.04.022 9. Okoli C, Pawlowski SD. The Delphi method as a research tool: An example, design considerations and applications. Inf Manag 2004;42(2):15-29. https://doi.org/10.1016/j.im.2003.11.002 10. Rasoulian M, Shirazi M, Nojomi M. Primary health care physicians’ approach toward domestic violence in Tehran, Iran. Med J Islam Repub Iran 2014;28(148):1-8. 11. Usta J, Hlais S, Farhat HA, Romani M, Bzeih H, Abdo L. Lebanese medical students’ exposure to domestic violence: Does it affect helping survivors? Fam Med 2014;46(2):112-119. 12. Federal Republic of Nigeria. National Gender Policy: Situation Analysis/Framework. Abuja: Federal Republic of Nigeria, 2006. 13. World Health Organization. Preventing Intimate Partner and Sexual Violence against Women: Taking Action and Generating Evidence. Geneva: WHO, 2010. https://doi.org/10.1136/ip.2010.029629 14. Feder GS, Hutson M, Ramsay J, Taket AR. Women exposed to intimate partner violence. Expectations and experiences when they encounter health care professionals: A meta-analysis of qualitative studies. Arch Intern Med 2006;166(1):22-37. https://doi.org/10.1001/archinte.166.1.22 15. Wathen CN, Tanaka M, Catallo C, et al. Are clinicians being prepared to care for abused women? A survey of health professional education in Ontario, Canada. BMC Med Educ 2009;9(34). https://doi.org/10.1186/14726920-9-34 16. Basile KC, Hertz MF, Back SE. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: Version 1. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2007. 17. Buranosky R, Hess R, McNeil MA, Aiken AM, Chang JC. Once is not enough: Effective strategies for medical student education on intimate partner violence. Violence Against Women 2012;18(10):1192-1212. https://doi. org/10.1177/1077801212465154 18. Centers for Disease Control. Intimate partner violence: Fact sheet, 2006. Atlanta: CDC, 2006. http:/www.cdc.gov/ ncipc/factsheets/ipvfacts.html (accessed 29 September 2015). 19. Ball CA, Kurtz AM, Reed T. Evaluating violent person management training for medical students in an emergency medicine clerkship. South Med J 2015;108(9):520-3. https://doi.org/10.14423/SMJ.0000000000000337 20. Farchi S, Polo A, Asole S, Ruggieri MP, Di Lallo D. Use of emergency department services by women victims of violence in Lazio region, Italy. BMC Women’s Health 2013;13:31. https://doi.org/10.1186/1472-6874-13-31 21. Fawole OI, Abass LW, Fawole AO. Prevalence of violence against pregnant women in Ibadan, Nigeria. Afr J Med Med Sci 2010;39(4):293-303. 22. Fawole OI, Aderonmu AL, Fawole AO. Intimate partner abuse: Wife beating among civil servants in Ibadan, Nigeria. Afr J Reprod Health 2005:54-64. 23. Petrosky M, Colaruotolo LA, Billings RJ, Meyerowitz C. The integration of social work into a postgraduate dental training program: A fifteen-year perspective. J Dental Educ 2009;73(6):656-664. 24. Tufts KA, Clements PT, Karlowicz KA. Integrating intimate partner violence content across curricula: Developing a new generation of nurse educators. Nurse Educ Today 2009;29(1):40-47. https://doi.org/10.1016/j. nedt.2008.06.005 25. Fawole OI, Ajuwon AJ, Osungbade KO. Evaluation of interventions to prevent gender-based violence among young female apprentices in Ibadan, Nigeria. Health Educ 2005;105(3):186-203. https://doi.org/ 10.1108/09654280510595254 26. Glick S. Domestic violence simulated patient case. MedEdPORTAL 2007;3:624. https://doi.org/10.15766/ mep_2374-8265.624

Accepted 15 January 2018.

Research

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

Self-reported generic learning skills proficiency: Another measure of medical school preparedness V C Burch,1 MB BCh, MMed, PhD, FCP, FRCP; C N T Sikakana,2 BSc, PhD; G D Gunston,3 MB ChB, MPhil Ed; D Murdoch-Eaton,4 MBBS, MD, FRCPCH Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa Division of Medical Biochemistry, Faculty of Health Sciences, University of Cape Town, South Africa 3 Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa 4 Medical School, Faculty of Medicine, Dentistry and Health, University of Sheffield, UK 1 2

Corresponding author: G D Gunston (Geney.gunston@uct.ac.za)

Background. Strong generic learning skills may improve academic performance at medical school. Studies evaluating the generic learning skills proficiency of medical students use self-reported data. It is not known whether self-evaluation of discipline-independent skills exhibits the same problems of widely variable accuracy as self-assessment of discipline-related skills. Objective. To investigate whether the self-reported generic learning skills proficiency of medical school entrants was related to three objective measures of performance: pre-university admission aptitude-test scores, information technology (IT) proficiency on entry and early academic performance at university. Methods. This prospective study used a previously validated 31-item questionnaire to document the self-reported proficiency of medical school entrants (2011 - 2013) with regard to 6 categories of generic learning skills: information handling, technical and numeracy, computer, organisational, managing self-learning and presentation skills. The results of the questionnaire were compared with performance in pre-university admission aptitude tests, an IT placement test on entry and end-of-semester 1 examinations (after 6 months at university), which are the basis for promotion to semester 2. Results. A total of 640 of 648 (98.8%) students completed the questionnaire. Self-reported generic learning skills proficiency was found to be significantly related to pre-university admission aptitude test scores (medium effect size), IT proficiency on entry to university (large effect size) and early academic performance at university (small effect size). Academically weak students did not overestimate their skills proficiency. Conclusion. These findings support the opinion that self-reported generic skills proficiency can credibly contribute to determining the academic preparedness of medical school entrants. Afr J Health Professions Educ 2018;10(2):114-123. DOI:10.7196/AJHPE.2018.v10i2.971

The contribution of discipline-independent cognitive skills to achieving success in higher education is increasingly acknowledged.[1-6] These skills are considered to be ‘important for individuals both as learners in foundation education and training, and as future employees in changing and flexible work roles’.[6] Referred to as key skills,[7] generic graduate attributes[8] or generic skills that underpin lifelong learning,[9] they usually relate to six broad categories of skills: number-based skills; communication skills; information and communication technology skills; the skills required to improve one’s own learning and performance; skills for problem-solving and skills for working with others.[4,10] Evidence is emerging that these underpinning generic learning skills may make an important contribution to academic performance in the first year at medical school.[11,12] Students experiencing academic difficulties in their first year at medical school report problems with information handling, problem solving, critical thinking and time management.[11] Academically at-risk medical students have been shown to have less practice, and confidence, in generic learning skills when compared with their peers on admission to university.[12] An academic support programme, purposefully designed to incorporate generic skills development, was found to close this ‘skills gap’ over a period of 12 months. These data suggest that generic skills proficiency may be a useful indicator of academic preparedness on entry to medical school. This may be particularly important in settings where widening participation in higher education is being pursued.

A number of studies on the generic skills proficiency of medical school entrants have been based on self-reported data.[12-14] This may be considered such a significant limitation of the work as to render the findings uninformative to the broader academic community. Correlations between self-assessment of discipline-specific knowledge and/or skills and external measures of performance have been shown to be widely variable in many disciplines, including medicine, education, law, engineering, sports science, behavioural science, psychology, guidance counselling, dietetics, and the workplace.[15-20] The reasons why self-assessment of both domain-specific knowledge and discipline-specific skills is unreliable are well known; high performers tend to underestimate their ability, and poor performers lack both the required expertise and insight to recognise their lack of expertise, i.e. they don’t know what they don’t know.[17,20-22] What is unknown, however, is whether self-assessment of generic learning skills, which are not discipline-specific, is subject to the same major limitations. In South Africa (SA), 17 of 26 public higher education institutions currently use the National Benchmark Tests (NBTs), alongside the National Senior Certificate and other high school-leaving examination results, to admit students who are likely to succeed at university.[23-29] The NBTs are a set of criterion-referenced pre-university admission aptitude tests, similar to pre-admission aptitude tests written in the UK (UK Clinical Aptitude Test),[30-32] the USA (North American Medical College Admission Test),[33,34] Australia (Australian Graduate Medical School Admissions Test)[35] and

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Research other countries such as Chile, Pakistan and Saudi Arabia.[36-38] These tests provide information about school-leavers that is supplementary to their pre-university academic achievements. As shown in Tables 1 A and B, the NBTs assess skills competency in three domains, namely academic literacy, quantitative literacy and mathematics.[29] The results are aggregated into three performance bands (proficient, intermediate and basic), which provide an indication of applicantsâ&#x20AC;&#x2122; academic preparedness and likely need for early academic support at university. The University of Cape Town (UCT) medical school accepts applicants who fall into the first two bands. Additionally, UCT uses a locally designed information technology (IT) placement test to identify medical school entrants who require additional intensive introductory IT training prior to starting semester 1. The semester 1 academic programme at UCT medical school consists of four courses: Chemistry, Physics, Introduction to Integrated Health Sciences (HUB1006F), and Becoming a Professional (BP).[39] HUB1006F introduces students to key physical, psychological, social and developmental concepts that shape the human life cycle from conception to death, via strategically designed problem-based learning cases. During this course, students gain an introductory overview of the human lifespan, and core discipline-

specific knowledge and skills including anatomy, physiology, psychology and sociology. BP aims to promote the conduct, knowledge, attitudes and values associated with being a professional and a professional team member. Students develop a range of skills, including interpersonal, interviewing and leadership skills, in addition to critical analysis and reflection on professional conduct, diversity, health and human rights. End of semester-1 examination results comprise the results of these four courses. The purpose of this study was to determine whether the self-reported generic learning skills proficiency of medical school entrants was related to objective measures of performance, specifically: pre-university admission aptitude test scores (NBTs), IT proficiency on admission to university (IT placement test), and academic performance after the first 6 months at university (end of semester-1 examination results, which are the basis for promotion to semester 2). Demonstrating a relationship between self-reported generic learning skills proficiency and objective measures of performance would be of international interest because it would support the hypothesis that selfassessment of such skills, which are discipline-independent, may be a credible way of determining academic preparedness for university, and

Table 1 A. Skills assessed in the three domain areas of the National Benchmark Tests (NBTs)[29] Academic literacy Making meaning from academic text Understanding vocabulary related to academic study Evaluating evidence used to support claims made by writers Extrapolating and drawing inferences and conclusions from text Differentiating main idea from supporting ideas in the overall and specific organisation of a passage Identifying text differences as related to the writersâ&#x20AC;&#x2122; purposes, audiences and forms of communication Understanding how syntax and punctuation are used to express meaning Understanding basic numerical concepts used in text

Quantitative literacy Applying quantitative procedures and reasoning in symbolic and non-symbolic situations Applying information from a variety of tables, graphs, charts and text Integrating information obtained from multiple sources Performing multiple-step calculations using information presented with text, symbols and graphs Identifying trends and patterns in various situations Applying properties of simple geometric shapes to determine measurements Interpreting quantitative information presented verbally, symbolically and graphically

Mathematics Understanding and applying properties of the real number system, including surds and exponents Recognising and using patterns, including sequences and series Applying relationships such as ratios and percentages in a variety of contexts Applying the results of algebraic manipulations with equations and inequalities Understanding the function concept and identifying properties of functions Interpreting transformations of functions represented algebraically or graphically Identifying relationships between graphs and their equations, or inequalities and the regions they describe Applying trigonometric identities and concepts in solving problems Understanding properties and interpreting representations of 2- and 3-dimensional shapes Applying principles of analytic geometry Interpreting various representations and measures of data Using logical skills in making deductions determining the validity of given assertions

Table 1 B. Interpretation of benchmark levels in the three domain areas of the National Benchmark Tests (NBTs)[29] Benchmark performance band (level) Proficient Intermediate

Basic

Performance band (level) descriptor Performance in domain areas suggests that academic performance will not be adversely affected. If admitted, students should be placed on regular programmes of study. Challenges in domain areas identified such that it is predicted that academic progress will be affected. If admitted, studentsâ&#x20AC;&#x2122; educational needs should be met in a way deemed appropriate by the institution (e.g. extended or augmented programmes, special skills provision). Serious learning challenges identified: it is predicted that students will not cope with degree-level study without extensive and long-term support, perhaps best provided through bridging programmes or FET colleges. Institutions registering students performing at this level would need to provide such support.

FET = Further Education and Training. FET colleges offer vocational and occupational courses which provide education and training with a specific range of jobs or employment possibilities.

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Research

Study participants

This was a prospective study of students entering year 1 of the UCT MB ChB programme during 2011 - 2013.

Survey instrument

Data were collected using a 31-item generic learning skills questionnaire previously validated in the SA context and shown to be reliable (Cronbach’s α = 0.88).[14] The clustering of the skills into 6 categories (informationhandling skills, technical and numeracy skills, computer skills, organisational skills, managing self-learning skills and presentation skills) was verified using factor analysis.[40] This questionnaire reports on learning skills proficiency in terms of: (i) frequency of practice of each of the 31 skills during the 12 months preceding entry into medical school, using a 4-point scale ranging from 1 (never) to 4 (every week), and (ii) level of self-confidence in performing these skills, using a 4-point rating scale from 1 (little or no experience), 2 (basic but I sometimes need help), 3 (enough for my needs) to 4 (more than I need, I often help others).

Procedure

On the first day of semester 1, at the end of the whole-class orientation session, all first-year medical students were fully briefed on the generic skills research project by the researcher, and given the opportunity to ask questions. Consenting students completed a specially designed paper-andpencil version of the questionnaire, which was handed to the researcher prior to leaving the venue. The data from the completed self-assessment questionnaires were electronically captured using a digital scanning process, and imported into Excel (Microsoft, USA) spreadsheets for analysis. Student data included the NBT scores, IT placement test scores and end of semester-1 examination results. All student data were obtained from student records kept in the Undergraduate Office at UCT medical school, and entered onto an Excel spreadsheet for analysis. All spreadsheets were manually checked for completeness prior to commencing data analysis.

Results

A total of 640 of the 648 (98.8%) students enrolled during the study period completed the survey. Fig. 1 shows the interrelationships between selfreported generic skills proficiency and the three objective measures of performance (NBT, IT placement test and semester 1 examinations). The figure summarises the effect size data presented in Tables 2 - 5. Tables 2 A - C compare students in the intermediate and proficient NBT performance bands for academic literacy, quantitative literacy and mathematics, with respect to performance in the IT placement test and semester 1 examinations. Overall, students in the proficient band performed significantly better than those in the intermediate band. Eighty percent of the effect sizes (12/15) were large or very large (≥0.75), and 20% (3/15) were medium (0.45 - 0.74). Tables 3 A - C compare students in the intermediate and proficient NBT performance bands for academic literacy, quantitative literacy and mathematics with respect to frequency of practice of, and confidence in, six categories of generic learning skills. Mostly, students in the proficient band reported significantly more frequent practice. The exceptions were non-significant differences between students in the two bands with respect to the frequency of practice of managing self-learning skills for all NBT components, and information handling for mathematics. While most (72%) effect sizes were small, that for academic literacy in relation to computer Semester 1 examinations

nd Ca Able s2 ( Ta rge La

Very large (Tables 4 A - D)

( Ta

d ate

lu va

Descriptive statistical and correlation analyses were performed using GraphPad Prism 6 (GraphPad Software Inc., USA). Means were compared

National Me Benchmark Tests

Generic skills Me d proficiency ium

Statistical analysis

m diu

s ble

Comparisons were made between the generic skills proficiency of students defined in three categories, according to student performance: (i) likely academic performance at university, as defined by two NBT benchmark performance bands (Table 1 B): intermediate (likely to require additional academic support), v. proficient (unlikely to need additional academic support) (ii) IT proficiency, as determined by IT placement test performance: <60% = not proficient (requires intensive introductory training prior to start of formal classes), v. ≥60% = proficient (introductory training not needed) (iii) early academic performance at university, as reflected by end of semester-1 examination results: <60% (poor academic performance) v. ≥60% (good academic performance).

Data analysis

Small (Tables 5 A - E)

Methods

using the unpaired t-test; where data sets showed unequal variance, the Welch correction was used. A p-value <0.05 was considered significant. The effect size for the means compared was calculated using a pooled standard deviation, which took into account the difference in size of the groups compared.[41] The Human Research Ethics Committee of the Faculty of Health Sciences, UCT (ref. no. 509/2013), and the Educational Research Ethics Committee of the Faculty of Medicine and Health, University of Leeds, UK (ref. no. 0607/ DME/SKILLS), approved the study.

-D )

the importance of generic learning skills in achieving success in higher education.[1,5,6]

( Ta

ble

A-

IT placement test

*Not relevant to the purpose of the study.

Fig. 1. Interrelationships between generic skills proficiency and performance prior to admission to university (NBT performance), on admission to university (IT placement test) and after 6 months at university (end of semester-1 examinations). Overall effect size of significant relationships and reference to the relevant data tables in the text are included.

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Research Table 2 A. Comparison of assessment outcomes for academic literacy: on entry (IT) and at end of semester 1 for MB ChB I students in intermediate and proficient NBT performance bands Assessment IT placement test Chemistry examination Physics examination HUB1006F examination BP examination

Intermediate (n=108) 56.3 (51.6 - 60.9) 54.2 (52.1 - 56.2) 55.7 (53.6 - 57.9) 56.7 (55.1 - 58.4) 68.6 (67.5 - 69.8)

Mean score, % (95% CI) (n=640) Proficient (n=532) Mean difference 77.4 (76.2 - 78.6) 21.14 62.3 (61.1 - 63.4) 8.08 65.7 (64.5 - 66.9) 9.96 67.6 (66.8 - 68.3) 10.83 74.0 (73.5 - 74.5) 5.36

Effect size, d* 1.60 0.63 0.77 1.19 0.99

p-value† <0.001 <0.00 <0.001 <0.001 <0.001

NBT = National Benchmark Test; HUB1006F = Introduction to Health Sciences Part I; BP = Becoming a Professional. *Effect size: <0.2 very small, ≥ 0.2 small, ≥ 0.45 medium, ≥ 0.75 large and ≥ 76 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

Table 2 B. Comparison of assessment outcomes for quantitative literacy: on entry (IT) and at end of semester 1 for MB ChB I students in the intermediate and proficient NBT performance bands Assessment event IT placement test Chemistry examination Physics examination HUB1006F examination BP examination

Intermediate (n=209) 64.3 (61.2 - 67.3) 53.8 (52.4 - 55.3) 55.6 (54.2 - 57.1) 59.8 (58.6 - 60.9) 70.6 (69.9 - 71.4)

Mean score, % (95% CI) (n=640) Proficient (n=431) Mean difference 78.8 (77.4 - 80.1) 14.50 64.3 (63.1 - 65.6) 10.53 68.1 (66.9 - 69.4) 12.52 68.6 (67.7 - 69.5) 8.82 74.3 (73.8 - 74.8) 3.68

Effect size, d* 1.06 0.87 1.03 0.97 0.67

p-value† <0.001 <0.001 <0.001 <0.001 <0.001

NBT = National Benchmark Test; HUB1006F = Introduction to Health Sciences Part I; BP = Becoming a Professional. *Effect size: < 0.2 very small, ≥ 0.2 small, ≥ 0.45 medium, ≥ 0.75 large and ≥ 1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

Table 2 C. Comparison of assessment outcomes for mathematics: on entry (IT) and at end of semester 1 for MB ChB I students in intermediate and proficient NBT performance bands Assessment IT placement test Chemistry examination Physics examination HUB1006F examination BP examination

Intermediate (n=273) 66.5 (64.1 - 68.9) 53.3 (52.1 - 54.5) 55.5 (54.3 - 56.7) 60.5 (59.5 - 61.5) 71.1 (70.5 - 71.7)

Mean score, % (95% CI) (n=640) Proficient (n=367) Mean difference 80.3 (79.0 - 81.7) 13.86 66.5 (65.2 - 67.8) 13.24 70.3 (69.1 - 71.7) 14.91 69.6 (68.7 - 70.6) 9.11 74.6 (74.0 - 75.2) 3.53

Effect size, d* 1.01 1.17 1.32 1.02 0.64

p-value† <0.001 <0.00 <0.001 <0.001 <0.001

NBT = National Benchmark Test; HUB1006F = Introduction to Health Sciences Part I; BP = Becoming a Professional. *Effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥76 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

Table 3 A. Comparison of mean generic learning skills category ratings for MB ChB I students in the intermediate and proficient NBT performance bands for academic literacy Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=640) Intermediate (n=108) Proficient (n=532) Mean difference

Effect size, d*

p-value

3.18 (3.07 - 3.30) 2.92 (2.82 - 3.03) 2.72 (2.56 - 2.87) 3.54 (3.44 - 3.63) 3.43 (3.35 - 3.51) 2.67 (2.56 - 2.78)

3.46 (3.43 - 3.50) 3.16 (3.12 - 3.20) 3.24 (3.20 - 3.29) 3.73 (3.69 - 3.77) 3.46 (3.43 - 3.50) 2.90 (2.85 - 2.94)

0.28 0.24 0.53 0.19 0.03 0.22

0.60 0.48 0.89 0.41 0.07 0.43

<0.001† <0.001† <0.001† 0.001 ns <0.001

2.74 (2.63 - 2.85) 2.68 (2.56 - 2.79) 2.52 (2.37 - 2.67) 3.06 (2.95 - 3.17) 3.09 (2.98 - 3.19) 2.46 (2.34 - 2.58)

3.14 (3.09 - 3.18) 3.02 (2.98 - 3.07) 3.13 (3.07 - 3.18) 3.29 (3.24 - 3.34) 3.21 (3.17 - 3.25) 2.87 (2.82 - 2.92)

0.40 0.35 0.61 0.23 0.12 0.41

0.76 0.65 0.94 0.42 0.26 0.73

<0.001 <0.001 <0.001† <0.001 <0.05† <0.001

NBT = National Benchmark Test; ns = not significant. *Effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance: p-value recalculated using Welch correction for unequal variance.

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Research Table 3 B. Comparison of mean generic learning skills category ratings for MB ChB I students in the intermediate and proficient NBT performance bands for quantitative literacy Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=640) Intermediate (n=108) Proficient (n=532) Mean difference

Effect size, d*

p-value†

3.31 (3.24 - 3.38) 2.97 (2.90 - 3.05) 2.88 (2.78 - 2.98)

3.47 (3.43 - 3.51) 3.19 (3.15 - 3.24) 3.28 (3.24 - 3.33)

0.16 0.22 0.41

0.33 0.44 0.68

<0.001† <0.001† <0.001†

3.63 (3.56 - 3.70) 3.42 (3.36 - 3.48) 2.75 (2.67 - 2.82)

3.73 (3.68 - 3.77) 3.47 (3.43 - 3.51) 2.91 (2.87 - 2.96)

0.09 0.06 0.17

0.20 0.14 0.32

<0.05 ns <0.001

2.85 (2.77 - 2.92) 2.74 (2.66 - 2.82) 2.71 (2.60 - 2.81) 3.13 (3.05 - 3.21) 3.11 (3.04 - 3.18) 2.60 (2.52 - 2.68)

3.18 (3.13 - 3.23) 3.07 (3.02 - 3.12) 3.18 (3.12 - 3.23) 3.31 (3.26 - 3.36) 3.23 (3.18 - 3.27) 2.90 (2.85 - 2.95)

0.33 0.33 0.47 0.18 0.11 0.30

0.63 0.63 0.73 0.33 0.25 0.52

<0.001 <0.001† <0.001† <0.001† <0.01 <0.001

Table 3 C. Comparison of mean generic learning skills category ratings for MB ChB I students in the intermediate and proficient NBT performance bands for mathematics Generic learning skills category on entry Frequency of practice

Mean rating of generic learning skills category (95% CI) (n=640) Intermediate (n=108) Proficient (n=532) Mean difference Effect size, d*

P-value

Information handling

3.38 (3.32 - 3.44)

3.44 (3.39 - 3.49)

0.06

0.12

ns†

Technical and numeracy

3.03 (2.97 - 3.09)

3.19 (3.14 - 3.24)

0.16

0.32

<0.001

Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

3.00 (2.90 - 3.07) 3.63 (3.57 - 3.69) 3.44 (3.39 - 3.50) 2.77 (2.71 - 2.84)

3.27 (3.22 - 3.33) 3.74 (3.70 - 3.79) 3.46 (3.42 - 3.51) 2.93 (2.87 - 2.98)

0.28 0.11 0.02 0.15

0.47 0.24 0.05 0.29

<0.001† <0.05† ns <0.001

2.88 (2.82 - 2.90) 2.77 (2.70 - 2.84) 2.78 (2.69 - 2.87) 3.14 (3.07 - 3.21) 3.15 (3.08 - 3.21) 2.64 (2.57 - 2.71)

3.21 (3.16 - 3.26) 3.11 (3.06 - 3.16) 3.21 (3.15 - 3.27) 3.33 (3.28 - 3.39) 3.22 (3.18 - 3.26) 2.92 (2.86 - 2.98)

0.32 0.33 0.43 0.19 0.07 0.28

0.62 0.64 0.66 0.35 0.16 0.50

<0.001 <0.001† <0.001† <0.001 ns† <0.001

NBT = National Benchmark Tests; ns = not significant. *Effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance: p-value recalculated using Welch correction for unequal variance.

Table 4 A. Comparison of pre-university NBT assessment outcomes v. entry IT placement test and semester 1 assessment outcomes for Chemistry

NBT domain Academic literacy Quantitative literacy Mathematics

IT placement test assessment on entry Mean percentage score (95% CI) (n=414) <60% (n=58 ) ≥60% (n=356) 61.6 (58.9 - 64.4) 74.8 (73.9 - 75.6) 54.7 (51.3 - 58.1) 74.0 (72.6 - 75.4) 51.6 (48.7 - 54.5) 65.2 (63.6 - 66.7)

Effect size, d* 1.58 1.45 0.94

p-value <0.001† <0.001 <0.001†

End of semester-1 assessment outcomes: Chemistry examination Mean percentage score (95% CI) (n=602) Effect <60% (n=282) ≥60% (n=320) size, d* p-value 70.0 (68.8 - 71.1) 75.9 (75.0 - 76.8) 0.65 <0.001† 64.8 (63.2 - 66.4) 77.7 (76.4 - 79.0) 1.00 <0.001† 57.0 (55.4 - 58.5) 72.3 (70.8 - 73.8) 1.16 <0.001

NBT = National Benchmark Tests. *Effect size: <0.1 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥ 1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

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Research Table 4 B. Comparison of pre-university NBT assessment outcomes v. entry IT placement test and semester 1 assessment outcomes for physics

NBT domain Academic literacy Quantitative literacy Mathematics

Effect size, d* 1.58 1.45 0.94

p-value <0.001† <0.001 <0.001†

End of semester-1 assessment outcomes: Physics examination Mean percentage score (95% CI) (n=607) Effect <60% (n=235) ≥60% (n=372) size, d* p-value 69.7 (68.5 - 71.0) 75.3 (74.4 - 76.2) 0.61 <0.001 63.1 (61.5 - 64.8) 77.0 (75.6 - 78.3) 1.08 <0.001 55.3 (53.8 - 56.9) 71.0 (69.6 - 72.4) 1.19 <0.001†

NBT = National Benchmark Tests. *Effect size: <0.1 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

Table 4 C. Comparison of pre-university NBT assessment outcomes v. entry IT placement test and semester 1 assessment outcomes for HUB1006F

NBT domain Academic literacy Quantitative literacy Mathematics

Effect size, d* 1.58 1.45 0.94

p-value <0.001† <0.001 <0.001†

End of semester-1 assessment outcomes: HUB1006F examination Mean percentage score (95% CI) (n=635) <60% (n=170) ≥60% (n=465) Effect size, d* p-value 66.9 (65.3 - 68.5) 75.5 (74.8 - 76.2) 1.00 <0.001† 63.5 (61.2 - 65.7) 75.0 (73.8 - 76.1) 0.86 <0.001 55.7 (53.8 - 57.7) 68.4 (67.1 - 69.8) 0.89 <0.001

NBT = National Benchmark Tests; HUB1006F = Introduction to Health Sciences Part I. *Effect size: <0.1 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

Table 4 D. Comparison of pre-university NBT assessment outcomes v. entry IT placement test and semester 1 assessment outcomes for BP

NBT domain Academic literacy Quantitative literacy Mathematics

Effect size, d* 1.58 1.45 0.94

P-value <0.001† <0.001 <0.001†

End of semester-1 assessment outcomes: BP examination Mean percentage score (95% CI) (n=455) Effect size, d* <60% (n=160) ≥60% (n=465) 67.8 (66.0 - 69.5) 75.3 (74.6 - 76.0) 0.85 66.1 (63.7 - 68.5) 74.4 (73.5 - 75.6) 0.60 59.7 (57.4 - 62.1) 67.4 (66.1 - 68.8) 0.52

P-value <0.001† <0.001† <0.001

NBT = National Benchmark Tests; BP = Becoming a Professional. *Effect size: <0.1 is very small, ≥0.2 is small, ≥0.45 is medium, ≥0.75 is large and ≥1 is very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

skills (6%) was large. The effect sizes for academic literacy in relation to information-handling and technical and numeracy skills, and those for quantitative literacy and mathematics in relation to computer skills (22%), were medium. In general, students in the proficient band reported significantly more confidence than those in the intermediate. The exception was the non-significant difference in confidence in managing self-learning skills between students in the two bands for mathematics. While most (55%) effect sizes were medium, those for academic literacy in relation to information-handling and computer skills (11%) were large. All effect sizes (33%) in relation to organisational skills and managing self-learning were small. Tables 4 A - D compare students’ results in the IT placement test or semester 1 examinations with their performance in the NBTs. Mostly, students who achieved a good pass (≥60%) in the IT placement test or semester 1 examinations had performed significantly better in the NBTs. Seventy-three percent of the effect sizes (11/15) were large or very large, and 27% (4/15) were medium. Tables 5 A - E compare students’ results in the IT placement test or semester 1 examinations with their frequency of practice of, and confidence in, the six generic learning skills categories. In general, students who achieved a good pass reported significantly more frequent practice. The

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exceptions were the non-significant differences between strong and weak performers in the frequency of practice of managing self-learning skills for the IT placement test or any semester 1 examinations, presentation skills for chemistry or HUB1006F and information-handling skills for chemistry, physics or HUB1006F. While most (87%) effect sizes were small, that for the IT placement test in relation to computer skills (3%) was very large. The effect sizes for the IT placement test in relation to technical and numeracy skills, and for HUB1006F and BP in relation to computer skills (10%) were medium. In general, students who achieved a good pass reported significantly more confidence. The exceptions were the non-significant differences in confidence in managing self-learning skills between strong and weak performers in the IT placement test or chemistry. Most effect sizes (63%) were small, but those for the IT placement test in relation to technical and numeracy skills and computer skills (7%) were large or very large. The effect sizes for the IT placement test in relation to information handling, organisational and presentation skills; physics in relation to information handling, technical and numeracy, and computer skills; HUB1006F in relation to computer skills; and BP in relation to information-handling and computer skills (30%) were medium. Correlation analyses were also performed for all the variables presented in Tables 2 - 5. In 87% (110/126) of comparisons, correlation coefficients

Research Table 5 A. Comparison of mean generic learning skills category ratings v. entry IT placement test results for MB ChB I students Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=414) <60% (n=58) ≥60% (n=356)

Effect size, d*

p-value

3.30 (3.17 - 3.42) 2.95 (2.83 - 3.08) 2.42 (2.22 - 2.62) 3.57 (3.46 - 3.68) 3.48 (3.36 - 3.59) 2.73 (2.59 - 2.87)

3.45 (3.40 - 3.50) 3.19 (3.15 - 3.24) 3.23 (3.17 - 3.28) 3.75 (3.70 - 3.79) 3.45 (3.41 - 3.50) 2.89 (2.84 - 2.94)

0.34 0.53 1.45 0.40 – 0.06 0.34

<0.05 <0.001 <0.001† <0.01 ns <0.05

2.75 (2.59 - 2.90) 2.65 (2.50 - 2.79) 2.24 (2.06 - 2.42) 3.05 (2.91 - 3.18) 3.09 (2.93 - 3.24) 2.49 (2.34 - 2.63)

3.13 (3.08 - 3.19) 3.04 (2.99 - 3.09) 3.11 (3.05 - 3.17) 3.31 (3.26 - 3.37) 3.20 (3.15 - 3.25) 2.87 (2.82 - 2.93)

0.72 0.78 1.46 0.49 0.24 0.72

<0.001 <0.001 <0.001 <0.001 ns <0.001

ns = not significant. *Effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

Table 5 B. Comparison of mean generic learning skills category ratings v. end of semester-1 examination results for chemistry Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=602) <60% (n=282) ≥60% (n=320)

Effect size, d*

p-value

3.36 (3.30 - 3.42) 3.03 (2.97 - 3.09) 3.01 (2.93 - 3.09) 3.62 (3.57 - 3.68) 3.43 (3.37 - 3.48) 2.81 (2.75 - 2.87)

3.43 (3.38 - 3.48) 3.15 (3.10 - 3.21) 3.21 (3.15 - 3.27) 3.74 (3.69 - 3.79) 3.48 (3.44 - 3.52) 2.87 (2.81 - 2.92)

0.14 0.25 0.33 0.25 0.13 0.11

ns† <0.01 <0.001† <0.01 ns ns

2.96 (2.90 - 3.02) 2.83 (2.76 - 2.90) 2.86 (2.77 - 2.95) 3.19 (3.12 - 3.25) 3.15 (3.09 - 3.21) 2.70 (2.64 - 2.77)

3.16 (3.10 - 3.22) 3.05 (3.00 - 3.11) 3.12 (3.05 - 3.19) 3.31 (3.25 - 3.37) 3.21 (3.16 - 3.26) 2.85 (2.79 - 2.92)

0.36 0.42 0.38 0.22 0.13 0.26

<0.001 <0.001 <0.001† <0.01 ns <0.01

ns = not significant. *Effect size: <0.2 is very small, ≥0.2 is small, ≥0.45 is medium, ≥0.75 is large and ≥1 is very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

reflected the effect sizes as follows: small effect sizes had r-values <0.25; medium effect sizes had r-values 0.25 - 0.40, and large effect sizes had r-values >0.4 (data not shown).

Discussion

This study showed that the self-reported practice of and confidence in generic learning skills proficiency of first-year medical students was related to three objective measures of performance: pre-university admission aptitude test scores, IT proficiency on entry to university and early academic performance at university. Since these findings are based on self-assessment data, the credibility of which is often contested in the medical education literature,[15-20] it is essential to substantiate our findings before discussing their significance. Factors which are known to influence the accuracy of self-assessment data, including the nature of the self-assessment task, and

the characteristics of the rating scales used,[42] are specifically addressed. Regarding the nature of the task, it is essential to recognise that the students in this study were asked to self-assess their generic learning skills proficiency rather than discipline-specific skills. This is important, because the challenges that students face when self-assessing discipline-specific skills were not relevant to this task. These challenges include students’ rudimentary understanding of the knowledge required to perform discipline-specific tasks proficiently,[22] the longstanding debate about the extent (breadth and depth) of profession-specific expertise required of medical graduates, i.e. curriculum content and overload,[43,44] and the observation that experts continue to display ‘disturbing discrepancies in their judgements of how much knowledge is enough’.[45] It is not, therefore, surprising that students may struggle to have a clear idea of discipline-specific proficiency and whether they have

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Research Table 5 C. Comparison of mean generic learning skills category ratings v. end of semester-1 examination results for physics Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=602) <60% (n=282) ≥60% (n=320)

Effect size, d*

p-value

3.37 (3.30 - 3.44) 3.01 (2.95 - 3.08) 2.99 (2.90 - 3.08) 3.61 (3.54 - 3.67) 3.42 (3.36 - 3.47) 2.77 (2.70 - 2.84)

3.42 (3.38 - 3.47) 3.17 (3.12 - 3.22) 3.20 (3.15 - 3.26) 3.74 (3.70 - 3.79) 3.47 (3.43 - 3.51) 2.89 (2.83 - 2.94)

0.11 0.31 0.35 0.29 0.13 0.21

ns† <0.001 <0.001† <0.001† ns <0.05

2.91 (2.84 - 2.98) 2.78 (2.71 - 2.86) 2.81 (2.72 - 2.91) 3.14 (3.07 - 3.21) 3.13 (3.07 - 3.19) 2.67 (2.59 - 2.74)

3.17 (3.11 - 3.22) 3.07 (3.02 - 3.12) 3.12 (3.06 - 3.18) 3.33 (3.27 - 3.38) 3.22 (3.17 - 3.27) 2.87 (2.81 - 2.92)

0.48 0.55 0.46 0.34 0.19 0.35

<0.001 <0.001† <0.001† <0.001 <0.05 <0.001

Table 5 D. Comparison of mean generic learning skills category ratings v. end of semester-1 examination results for HUB1006F Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=635) <60% (n=170) ≥60% (n=465)

Effect size, d*

p-value

3.35 (3.27 - 3.44) 3.03 (2.94 - 3.11) 2.95 (2.83 - 3.06) 3.59 (3.51 - 3.66) 3.43 (3.36 - 3.50) 2.81 (2.73 - 2.89)

3.44 (3.40 - 3.48) 3.16 (3.11 - 3.20) 3.23 (3.18 - 3.27) 3.73 (3.69 - 3.77) 3.47 (3.43 - 3.51) 2.88 (2.83 - 2.93)

0.18 0.25 0.46 0.31 0.09 0.13

ns <0.01† <0.001† <0.001 ns ns

2.94 (2.85 - 3.03) 2.83 (2.74 - 2.92) 2.79 (2.67 - 2.91) 3.15 (3.07 - 3.23) 3.12 (3.05 - 3.20) 2.68 (2.59 - 2.77)

3.12 (3.07 - 3.17) 3.01 (2.97 - 3.06) 3.11 (3.05 - 3.17) 3.29 (3.24 - 3.34) 3.21 (3.17 - 3.25) 2.85 (2.80 - 2.90)

0.34 0.34 0.48 0.25 0.19 0.30

<0.001 <0.001 <0.001† <0.01 <0.05 <0.01

HUB1006F = Introduction to Health Sciences Part I; ns = not significant. *Effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

achieved it. The same, however, is not true of discipline-independent generic learning skills. Furthermore, the self-assessment process in this study reported on students’ prior experience of performing objective, well-defined, familiar activities, such as answering emails, or finding information on the internet. Self-assessment of such activities has been shown to be better aligned with objective performance data.[17,20,46,47] In addition, the skills self-assessed in this study were largely ‘observable’, and, like language proficiency and sports performance, can be more accurately self-assessed than cognitive skills such as clinical reasoning.[20] This point is well illustrated in our study, where sudents who performed poorly in the IT placement test appropriately rated themselves as less experienced and confident in their computer skills. This finding also suggests that poor performers may recognise their limitations if self-assessment tasks focus on familiar, observable, non-cognitive skills.

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A significant problem with self-assessment studies is the variable use of rating scales by participants.[42] In our study, this limitation was addressed by using rating scales that were comparative (to peers), quantitative and objectively anchored. Such scales have been shown to yield more robust self-assessment data.[46,47] Peer comparison probably served as an indirect source of feedback, which is known to further enhance the accuracy of self-assessment of skills.[17,46] For example, students who rated themselves as ‘know more than I need – I often assist others’ were more likely to have been approached repeatedly for help by peers who recognised their ability based on prior performance. Having addressed the key potential limitation of this study, the salient findings can now be discussed. Overall, they show that the relationship effect sizes for students’ self-reported confidence in their generic learning skills v. their academic results were greater than for self-reported frequency

Research Table 5 E. Comparison of mean generic learning skills category ratings v. end of semester-1 examination results for BP Generic learning skills category on entry Frequency of practice Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills Confidence Information handling Technical and numeracy Computer skills Organisational skills Managing self-learning Presentation skills

Mean rating of generic learning skills category (95% CI) (n=615) <60% (n=160) ≥60% (n=465)

Effect size, d*

p-value

3.25 (3.17 - 3.34) 3.06 (2.97 - 3.14) 2.91 (2.79 - 3.03) 3.54 (3.45 - 3.62) 3.40 (3.34 - 3.46) 2.77 (2.68 - 2.86)

3.46 (3.42 - 3.50) 3.17 (3.12 - 3.21) 3.22 (3.17 - 3.27) 3.74 (3.70 - 3.78) 3.46 (3.43 - 3.50) 2.89 (2.84 - 2.94)

0.44 0.22 0.51 0.44 0.15 0.23

<0.001† <0.05† <0.001† <0.001† ns <0.05

2.90 (2.80 - 2.99) 2.89 (2.81 - 2.98) 2.78 (2.66 - 2.91) 3.09 (3.01 - 3.17) 3.10 (3.03 - 3.18) 2.67 (2.57 - 2.76

3.14 (3.09 - 3.19) 3.01 (2.96 - 3.06) 3.10 (3.04 - 3.16) 3.30 (3.25 - 3.35) 3.21 (3.17 - 3.26) 2.84 (2.79 - 2.90)

0.45 0.21 0.48 0.38 0.24 0.30

<0.001† <0.05 <0.001† <0.001 <0.01 <0.01

BP = Becoming a Professional; ns = not significant. *Effect size: <0.2 very small, ≥0.2 small, ≥0.45 medium, ≥0.75 large and ≥1 very large. † Unequal variance; p-value recalculated using Welch correction for unequal variance.

of practice v. academic results. This makes sense, because practical skill proficiency is influenced by many factors other than frequency of practice. It is noteworthy that generally, the effect sizes were small for organisational skills, and largely insignificant for managing self-learning skills. This also makes sense, because such skills are unlikely to significantly influence aptitude test (NBTs) performance or IT proficiency, and the limited curriculum load in first year may not require well-developed organisational and self-learning management skills. These skills may, however, become more important in later years of study, where the large volume of work is likely to require them. This merits further exploration. Internationally, there is a call for more studies aimed at determining the content and format of academic support programmes that promote sustained academic success.[48] The work presented in this article supports a focus on generic learning skills development, in addition to discipline-specific knowledge and skills learning, in such programmes.[12] The questionnaire used in the study may facilitate the conceptualisation of academic support programmes that better suit students’ needs, and direct timeous allocation of extra resources on a needs rather than ad hoc basis that may jeopardise the sustainability of such programmes. Since the questionnaire is free and easy to administer, it may be particularly attractive in limited-resource settings where strategies for providing early academic support are likely to be most needed. While the findings of this study are limited to one institution, the results are encouraging, and the sample size was sufficiently large to provide meaningful data. This provides a clear mandate to conduct a multicentre study. The results also support the idea that self-assessed generic skills proficiency may be a welcome addition to university admissions and academic placement processes, to determine the academic preparedness of students from diverse backgrounds, and to further support efforts to improve the social mobility of all sectors of society.[49] Acknowledgements. The authors would like to acknowledge Vanessa Gray from the University of Leeds for her assistance with data processing. Author contributions. GDG gathered the generic learning skills data provided

by consenting students on a specially designed paper-and-pencil version of the questionnaire. The data were electronically captured using a digital scanning process, and imported into Excel (Microsoft, USA) spreadsheets for analysis (DM-E). Student data (NBT scores, IT placement test scores and end of semester-1 examination results) were obtained from student records kept in the Undergraduate Office at UCT medical school, and entered onto an Excel spreadsheet for analysis. All spreadsheets were manually checked for completeness prior to commencing data analysis (VB and CS). All authors contributed to the review of literature, discussion of results and writing of the article. Funding. Travel expenses for DM-E and some administrative and data processing in the UK were supported by DM-E’s National Teaching Fellowship awarded by the Higher Education Academy, UK. Conflicts of interest. None. 1. Dearing R. Higher Education in the Learning Society: Report of the National Committee of Inquiry into Higher Education. London: Department for Education and Employment, 1997. 2. Credé M, Kuncel NR. Study habits, skills, and attitudes: The third pillar supporting collegiate academic performance. Perspect Psychol Sci 2008;3(6):425-453. https://doi.org/10.1111/j.1745-6924.2008.00089.x 3. Collin VT, Violato C, Hecker K. Aptitude, achievement and competence in medicine: A latent variable path model. Adv Health Sci Educ 2009;14(3):355-366. https://doi.org/10.1007/s10459-008-9121-7 4. Jones A. Generic attributes as espoused theory: The importance of context. High Educ 2009;58(2):175-191. https://doi.org/10.1007/s10734-008-9189-2 5. 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 6. Green A. Core skills, key skills and general culture: In search of the common foundation in vocational education. Eval Res Edu 1998;12(1):23-43. https://doi.org/10.1080/09500799808666929 7. Washer P. Revisiting key skills: A practical framework for higher education. Qual High Educ 2007;13(1):57-67. http://doi.org/10.1080/13538320701272755 8. Barrie S. A conceptual framework for the teaching and learning of generic graduate attributes. Stud High Educ 2007;32(4):439-458. https://doi.org/10.1080/03075070701476100 9. Murdoch-Eaton D, Whittle S. Generic skills in medical education: Developing the tools for successful lifelong learning. Med Educ 2012;46(1):120-128. https://doi.org/10.1111/j.1365-2923.2011.04065.x 10. Mayer E, Australian Educational Council, Mayer Committee. Putting general education to work: The key competencies report. Melbourne: Australian Education Council and Ministers of Vocational Education, Employment and Training, 1992. http://hdl.voced.edu.au/10707/72980 (accessed 11 June 2018). 11. Paul G, Hinman G, Dottl S, Passon J. Academic development: A survey of academic difficulties experienced by medical students and support services provided. Teach Learn Med 2009;21(3):254-260. https://doi. org/10.1080/10401330903021041 12. Burch VC, Sikakana CNT, Gunston G, Shamley DR, Murdoch-Eaton D. Generic learning skills in academicallyat-risk medical students: A development programme bridges the gap. Med Teach 2013;35(8):671-677. https://doi. org/10.3109/0142159X.2013.801551 13. McLean M, Shaban S, Murdoch-Eaton D. Transferable skills of incoming medical students and their development over the first academic year: The United Arab Emirates experience. Med Teach 2011;33(6):e297-e305. https://doi. org/10.3109/0142159X.2011.565826 14. Murdoch-Eaton D, Manning D, Kwizera E, Burch V, Pell G, Whittle S. Profiling undergraduates’ generic learning skills on entry to medical school: An international study. Med Teach 2012;34(12):1033-1046. https://doi.org/10 .3109/0142159X.2012.706338

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Research 15. Falchikov N, Boud D. Student self-assessment in higher education: A meta-analysis. Rev Educ Res 1989;59(4):395430. https://doi.org/10.3102/00346543059004395 16. Gordon MJ. A review of validity and accuracy of self-assessments in health professions training. Acad Med 1991;66(12):762-769. 17. Dunning D, Heath C, Suls JM. Flawed self-assessment: Implications for health, education and the workplace. Psych Science Public Interest 2004;5(3):69-106. https://doi.org/10.12691/ajrd-5-3-3 18. Eva KW, Regehr G. Self-assessment in the health professions: A reformulation and research agenda. Acad Med 2005;80(Suppl 10):S46-S54. 19. Davis DA, Mazmanian PE, Fordis M, Harrison RV, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence. A systematic review. JAMA 2006;296(9):1094-1102. https:// doi.org/10.1001/jama.296.9.1094 20. Zell E, Kristan Z. Do people have insight into their abilities? A metasynthesis. Perspect Psychol Sci 2014;9(2):111125. https://doi.org/10.1177/1745691614521244 21. Dunning D, Johnson K, Ehrlinger J, Kruger J. Why people fail to recognize their own incompetence. Curr Dir Psychol Sci 2003;12(3):83-87. https://doi.org/10.1111/1467-8721.01235 22. Eva KW, Cunnington JPW, Reiter HI, Keane DR, Norman GR. How can I know what I don’t know? Poor self-assessment in a well-defined domain. Adv Health Sci Educ 2004;9(3):211-214. https://doi.org/10.1023/ B:AHSE.0000038209.65714.d4 23. South Africa. Department of Education White Paper 3: A programme for the transformation of higher education. http://www.che.ac.za/sites/default/files/publications/White_Paper3.pdf (accessed 11 June 2018). 24. Griesel H. Access and Entry Level Benchmarks: The National Benchmark Tests Project. Pretoria: Higher Education South Africa (HESA), 2006. 25. Rankin N, Schöer V, Sebastiao C, Van Walbeek C. Predictors of academic performance: National Senior Certificate v. National Benchmark Tests. S Afr J High Educ 2012;26(3):564-585. 26. Wilson-Strydom M. Using the NBTs to inform institutional understandings of ‘under-preparedness’: Implications for admissions criteria. S Afr J High Educ 2012;26(1):136-151. 27. Cliff A. The National Benchmark Test in academic literacy: How might it be used to support teaching in higher education? Lang Matters 2015;46(1):3-21. https://doi.org/10.1080/10228195.2015.1027505 28. Wadee AA, Cliff A. Pre-admission tests of learning potential as predictors of academic success of first-year medical students. S Afr J High Educ 2016;30(2):264-278. http://doi.org/10.20853/30-2-619 29. Centre for Educational Testing for Access and Placement. What is in the NBTs? 2016. http://www.nbt.ac.za/ content/what-nbts (accessed 11 June 2018). 30. McManus IC, Smithers E, Partridge P, Keeling A, Fleming PR. A Levels and intelligence as predicators of medical careers in UK doctors: 20 year prospective study. BMJ 2003;327(7407):139-142. https://doi. org/10.1136%2Fbmj.327.7407.139 31. Adam J, Dowell J, Greatrix R. Use of UKCAT scores in student selection by UK medical schools, 2006 - 2010. BMC Med Educ 2011;11:98. https://doi.org/10.1186/1472-6920-11-98 32. McManus IC, Dewberry C, Nicholson S, Dowell JS. The UKCAT-12 study: Educational attainment, aptitude test performance, demographic and socio-economic contextual factors as predictors of first year outcome in a crosssectional collaborative study of 12 UK medical schools. BMC Med 2013;11:244. https://doi.org/10.1186/17417015-11-244 33. Donnon T, Paolucci EO, Violato C. The predictive validity of the MCAT for medical school performance and medical board licensing examinations: A meta-analysis of the published research. Acad Med 2007;82(1):100-106. https://doi.org/10.1097/01.ACM.0000249878.25186.b7

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34. Callahan CA, Hojat M, Velsoki J, Erdmann JB, Gonnella JS. The predictive validity of the three versions of the MCAT in relation to performance in medical school, residency, and licencing examinations: A longitudinal study of 36 classes of Jefferson Medical College. Acad Med 2010;85(6):980-987. https://doi.org/10.1097/ ACM.0b013e3181cece3d 35. Coates H. Establishing the criterion validity of the Graduate Medical School Admissions Test (GAMSAT). Med Educ 2008;42(10):999-1006. https://doi.org/10.1111/j.1365-2923.2008.03154.x 36. Contreras R, Ubilla S, Ugalde H, Vincentini E. Comparative study of the academic aptitude test and final grading in Chilean medical schools. Rev Med Chile 1984;112(10):1033-1043. 37. Al Alwan I, Al Kushi M, Magzoub M, Elzubeir M. Health sciences and medical college preadmission criteria and prediction of in-course academic performance: A longitudinal study. Adv Health Sci Educ 2013;18(3):427-438. https://doi.org/10.1007/s10459-012-9380-1 38. Khan JS, Tabasum S, Mukhtar O. Comparison of pre-medical academic achievement, entrance test and aptitude test scores in admission selection process. J Pakistan Med Assoc 2013;63(5):552-557. 39. University of Cape Town. Faculty of Health Sciences Undergraduate Studies: 2016. Handbook 8a in this series of handbooks. Rules And Curricula For Undergraduate Programmes Bachelor of Medicine and Bachelor Of Surgery (MBChB) pp 24-25. http://www.uct.ac.za/usr/downloads/uct.ac.za/apply/handbooks/Handbook8A_ HealthSciencesUndergraduate_2016.pdf (accessed 11 June 2018). 40. Whittle SR, Pell G, Murdoch-Eaton DG. Recent changes to students’ perceptions of their key skills on entry to higher education. J Further High Ed 2010;34(12):557-570. https://doi.org/10.3109/0142159X.2012.706338 41. Lenhard W, Lenhard A. Calculation of Effect Sizes. Bibergau: Psychometrica, 2016. http://www.psychometrica. de/effect_size.html. (accessed 11 June 2018). 42. Ward M, Gruppen L, Regehr G. Measuring self-assessment: Current state of the art. Adv Health Sci Educ 2002;7(1):63-80. 43. Anderson J, Graham A. A problem in medical education: Is there an information overload? Med Educ 1980;14(1):4-7. 44. Jones R, Higgs R, de Angelis C, Prideaux D. Changing face of medical curricula. Lancet 2001;357(9257):699-703. https://doi.org/10.1016/S0140-6736(00)04134-9 45. Bergman EM, Prince KJ, Drukker J, van der Vleuten CP, Scherpbier AJ. How much anatomy is enough? Anat Sci Educ 2008;1(4):184-188. https://doi.org/10.1002/ase.35 46. Goffin RD, Olson JM. Is it all relative? Comparative judgements and the possible improvement of self-ratings and ratings of others. Perspect Psychol Sci 2011;6(1):48-60. https://doi.org/10.1177/1745691610393521 47. Freund PA. How smart do you think you are? A meta-analysis on the validity of self-estimates of cognitive ability. Psychol Bull 2012;138(2):296-321. https://doi.org/10.1037/a0026556 48. Cleland J, Leggett H, Sandars J, Costa MJ, Patel R, Moffat M. The remediation challenge: Theoretical and methodological insights from a systematic review. Med Educ 2013;47(3):242-251. https://doi.org/10.1111/ medu.12052 49. Milburn A. Fair Access to Professional Careers: A Progress Report by the Independent Reviewer on Social Mobility and Child Poverty. London: The National Archives, 2012. https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/61090/IR_FairAccess_acc2.pdf (accessed 11 June 2018).

Accepted 5 October 2017.

Research

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

Integrating critical cross-field outcomes in an anatomy course at a university of technology: A reflective perspective J D Pillay,1 PhD; N Govender,1 PhD; N Lachman,2 PhD 1

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

Department of Anatomy, Faculty of Health Sciences, Mayo Clinic, Rochester, MN, USA

Corresponding author: N Govender (nalinip@dut.ac.za)

Background. Recent trends in higher education have become particularly directed towards incorporating elements of general education in professionspecific training. Consequently, the inclusion of critical cross-field outcomes (CCFOs) – a set of generic outcomes gazetted by the South African Qualification Authority – in curricula, is directed towards stimulating a critical social conscience among students. This embraces the concept of education, more than simply certification, in embedding underlying principles that foster lifelong learning, critical thinking and social responsibility, and provides an opportune platform to examine our teaching strategies in the context of reflective practice. Objectives. This article demonstrates an application of the theory of reflective practice in the modification of teaching strategies and the integration of the CCFOs in a human anatomy course at a university of technology. Methods. We present the different teaching strategies that were applied, and highlight the CCFOs embodied in each approach. Results. In so doing, we demonstrate how the integration of underpinning general education principles and discipline-specific core competencies can be easily attained through simple modifications of conventional teaching practices. Conclusion. The teaching methods highlighted attempt to encourage and ensure that students evaluate, understand and apply their knowledge in an integrated and shared manner, as embraced by the CCFOs. Afr J Health Professions Educ 2018;10(2):124-128. DOI:10.7196/AJHPE.2018.v10i2.960

South African (SA) higher education institutions are aligned to the Higher Education Qualifications Framework (HEQF), which is committed towards creating discipline-specific learning programmes that underpin the critical cross-field outcomes (CCFOs).[1] These outcomes, gazetted by the SA Qualification Authority (SAQA),[2,3] are defined as generic outcomes directed towards stimulating a critical social conscience among students. These embrace the concept of ‘life-long learning, personal growth, honest business acumen, critical thinking and aesthetic appreciation’,[4] and form standard competencies that are intended to underpin all qualifications registered on the National Qualifications Framework (NQF).[4] Split into seven critical and five developmental outcomes, the CCFOs include: the identification and solving of problems using critical and creative thinking; the use of effective teamwork within study groups, organisations and communities; organising and managing oneself and one’s activities conscientiously; collecting, analysing, organising and critically evaluating information; communicating effectively using visual or language skills via oral and/or written presentations; using science and technology effectively and successfully demonstrating an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation.[5] Recently popularised as graduate attributes, the CCFOs contribute soft skills towards empowering students to become more socially aware and responsible citizens.[6] The aspiration to develop graduate attributes at an institution forms part of the drivers’ encompassing innovation towards quality enhancement and improving the student experience, as well as creating a well-rounded graduate (K Sattar and L Cook – unpublished data,

2014). Teaching strategies therefore require reflection and consequent adaptation in an attempt to integrate discipline-specific knowledge with graduate attributes, as is promoted and required of the institution and higher education (HE). Contemporary studies suggest that to improve and promote student learning, current curricula must explore and maximise the benefits of different teaching methods.[7,8] A popularised approach in engaging academics towards exploring changes in teaching strategies pivots around theories on reflective practice. One of the more commonly referenced models of reflective practice is provided by Kolb,[9] who identifies four learning stages and cycles, i.e. the concrete experience (a new experience of a situation that is encountered or a re-interprtetation of an existing experience); reflective observation (of the new experience); abstract conceptualisation (reflection giving rise to a new idea or the modification of an existing concept); and active experimentation (applying the experience globally). According to Kolb, teachers could use this framework to critically evaluate a learning provision typically available to students and to develop more appropriate teaching/learning approaches. Academic and clinical components of formal training of most medical training programmes include anatomy as an integral component of the programme, particularly taught during the first 2 years of the academic course. Consequently, an attempt towards integrating graduate attributes in the anatomy course provides an early opportunity to exercise awareness of the CCFOs that can contribute towards such an application becoming instrinsic in the learning experience over subsequent academic years. While human dissection supplemented by formal lectures forms the basis of most

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Research anatomy courses, learning, both in the dissection laboratory and outside the classroom/laboratory setting, can be achieved by different teaching and learning strategies that embrace the CCFOs. This article demonstrates an application of the theory of reflective practice in the modification of teaching strategies and the integration of the CCFOs in a human anatomy course at a university of technology. A synopsis of teaching practices that have been introduced/modified in the course to integrate the CCFOs into subject-specific content, is presented.

Methods

The Anatomy II course that is taught to allied health students within the homoeopathy and chiropractic second-year programme is primarily dissection based and includes didactic teaching (two 1-hour theory sessions per week) and practicals/dissections (three 1-hour sessions twice a week) over a 32-week year. The course is taught in the second academic year of the programme, with students having completed a similarly structured Anatomy I course during the first yearof the programme. As a follow-on from Anatomy I, the Anatomy II course includes limb and back anatomy, neuroanatomy and head and neck anatomy. As such, the anatomy of the entire human body is completed by the end of the second academic year. In highlighting some of the changes in teaching approaches within this course, the different components of the theory of reflective practice and the methodological approaches applied within each cycle of the theoretical model are summarised.

Conceptual model for reflective thinking/practice

This article highlights the application of Kolb’s[9] model on the theory of reflective practice, which identifies four learning stages/cycles that form the basis of reflective practice, i.e. the concrete experience; reflective observation; abstract conceptualisation; and active experimentation. In the context of our study, the concrete experience relates to the introduction of innovative teaching and assessment approaches and forms the basis of this article. Much of this application relates to the fourth phase of reflective practice, i.e. active experimentation, as being the impetus for initiating the concrete experience. This is based on previous/conventional teaching and learning practices, lecturer and subject evaluations by students and consequent self-reflection in terms of ‘How we do what we do’ and more importantly, ‘How can we effect change to improve teaching and learning?’. There are also secondary aspects that may prompt reasons for innovative teaching. In the case of this course in human anatomy, one such reason relates to the diverse learning abilities and learning styles of students in a class. A further intrinsic motivation pivots around the need to integrate

the CCFOs into teaching and learning. Reflective observation centres on thinking about the experience, while abstract conceptualisation is based on the notion of learning from the experience.[9] Much of these two phases are unravelled in our article, collectively through the viewpoints of the lecturer and highlighted in the discussion. The changes in teaching strategies implemented in the course are outlined in Table 1. The different modes of teaching strategies implemented included assignments and projects, integrated theory and practical sessions and team teaching through dissection projects.

Assignments and projects

The traditional approach included individual written assignments, e.g. to provide an account on the brachial plexus and its contributions toward the movement of the upper limb. The modified approach in this strategy was the allocation of task-specific team assignments that involved model construction related to specific body systems and their functional demonstration. Examples of such task-specific assignments included either the design of a model of the upper limb to illustrate the muscle compartments of each region, and the demonstration of its functionality as a system of levers, or the design of a three-dimensional model of the head and neck region, demonstrating the dural venous sinuses of the brain.

Theory and practical sessions

Traditionally, this approach involved independent didactic lectures, followed by dissection sessions, which were modified by integrating both lectures and practical sessions, coupled with the demonstration of models and prosected specimens that enabled immediate integration of both theoretical and practical elements.

Cadaveric dissections during practical sessions

Traditionally, formal lectures on specific anatomical areas were conducted by an academic. Students were then assigned to dissection teams that worked on an allocated cadaver. The extent of learning and personal accountability was variable and depended on the extent of involvment of each team member and their ability/interest to work together. The modified approach included team teaching through the introduction of dissection projects during the practical sessions. Teams comprised 5 - 6 students, who were allocated specific dissection areas of their cadaver. Each team was required to present the specific topic/area and demonstrate their dissection area to the class in formats such as video clips, practical demonstrations, posters, PowerPoint presentations, traditional didactic teaching or a combination of one or more of these methods. Completion of this activity as a learning

Table 1. Traditional and modified approaches to teaching and learning Mode of teaching Assignment/project

Integrated theory/practical sessions Team teaching by means of dissection projects

125

Traditional approach Written assignment

Modified approach Task-specific assignment, which involves model construction related to specific body systems and their functional demonstration PowerPoint lecture and separate Combined lectures with the demonstration of models/ practical/dissection sessions prosected specimens Delivery (by lecturer) of formal lectures Team teaching through dissection projects on specific anatomical areas Review of learnt content by viva voce (oral assessment) and an Dissection teams work together in assessment mark determined by the entire team dissecting the allocated cadaver

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Research outcome was achieved by engaging students in collective learning, even outside time-tabled sessions. Team members were therefore required to strategise conducive ways of working together, such as convenient meeting times, dates, venues or allocation of tasks within the project. Post-practical sessions were also included to recapitulate key concepts and assist with any challenges experienced. This strategy included oral and post-dissection assessments as a tool to determine the level of learning achieved and the quality of dissection conducted. The final assessment mark was agreed upon by all team members; teams were thus accountable for both the learning and assessment outcomes of the exercise.

The study explored the use of the making-thinking-visible approach and highlighted two themes, i.e. the students’ understanding of the reasoning process and the increased knowledge of individual teaching approaches to demonstrating clinical reasoning.[12] The study concluded that the makingthinking-visible approach may support educators in articulating their own expert reasoning, as well as being a potential mechanism for personal reflection.[12] In our study, teamwork formed the basis of all the approaches used and required an effective, responsible and interactive collaboration of all team members, with the intent of enhancing personal reflection and critical thinking.

Results

Team assignments/projects

The modified teaching strategies implemented in relation to the seven CCFOs are shown in Table 2. Our results highlight the changes made to the anatomy curriculum in the context of integrating the CCFOs. Details of the modifications are presented in the methods section of this article.

Discussion

Allied health professionals, regardless of their occupational role, career stage or employment status, are required to be professionally competent when they exit HE institutions[10] and enter the workforce. Therefore, HE training needs to provide professional competence that embraces the graduates’ attributes. Studies conducted in the UK corroborate this need by highlighting a professional competence framework essential for enhancing the productivity of allied health professionals.[10] These studies concluded that allied health professionals will only be able to face the forthcoming challenges if they are open to opportunities to develop reflective thinking skills that foster useful engagement and support continued professional development.[10] Recent studies highlighted the need for educators to be more reflective about their teaching approaches towards critical thinking and clinical reasoning.[11,12] While clinical reasoning is a key aspect of medical practice, the complexity linked to teaching and learning is most difficult owing to its invisibility to students.[12] Some investigators explored the use of action research,[13] in which participant engagement is promoted within a structured means of reflection regarding their teaching practices.[14]

Model construction required the interactive engagement of students to generate a functional anatomical form of the upper limb, whose functionality was determined by its movement and biomechanics. This strategy improved student creativity and problem-solving skills linked to model functionality in relation to limb anatomy. All the required CCFOs (i.e. CCFOs 1 - 7) were achieved as an otcome of this strategy. Similarly, other studies using strategies such as casts,[14] body painting,[15] clay modelling[16] and construction of three-dimensional models[17] highlight the potential value of their use as a supplement to teaching standard anatomical principles. The use of model construction in our study required extensive planning, creativity and preparation, which subsequently developed problem-solving skills to produce an aesthetically appealing, scientifically relevant and mechanically functional product. Lefroy et al.[17] reinforced teaching of the brachial plexus using three-dimensional pipe models. These investigators showed that the use of such models improved students’ understanding of specific areas of the plexus. The combination of knowledge-based and skills-based teaching, its application and assessment, are demonstrated in the achievement of CCFO 7. This CCFO highlighted the inter-relatedness of systems, processes and effects, and enabled multidisciplinary engagement of disciplines such as physics (through the system of levers that bring about movement), chemistry (through the chemical reactions responsible for muscle contraction and consequent movement) and biomechanics (through the application of concepts around synergism and antagonism). This was similar to the learning activity in which the dural venous sinuses of the

Table 2. Teaching strategies applied to integrate the critical cross-field outcomes

Critical cross-field outcome 1. Identifying and solving problems in which responses demonstrate that responsible decisions using critical and creative thinking have been made 2. Working effectively with others as a member of a team, group, organisation or community 3. Organising and managing oneself and one’s activities responsibly and effectively 4. Collecting, analysing, organising and critically evaluating information, integrating teaching and learning 5. Communicating effectively using visual or language skills in modes of oral and/or written presentation 6. Using science and technology effectively and critically 7. Demonstrating an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation

Assignment √

Modified teaching strategies Integrated theory/ Team teaching through practical sessions dissection projects √

√

√ √

√

√ √

√

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Research brain were demonstrated. The application of knowledge of concepts such as volume, density and flow, acquired through multidisciplinary integration of knowledge, demonstrated their inter-relatedness. The teamwork underlying these activities supports peer learning and promotes independent and critical analyses and review of all information provided by each team member, thereby enhancing the skill of being able to distinguish between relevant and irrelevant information. This outcome supported the acquisition of CCFO 4, in which skills appropriate to collecting and organising relevant information are achieved. This further promoted the conscious awareness of having a critical and analytical approach to gathering, analysing and evaluating information.

Integrated theory and practical sessions

Integrating anatomy lectures and practicals can be applied to foster selfdirected learning and reflective practice.[18] Combining several teaching approaches, such as traditional didactic teaching, cadaveric dissections, prosections, plastination and medical imaging, complements each other and benefits the learning experience.[18] Critical and creative thinking is therefore achieved as students develop unique ways of linking the dissected areas with theoretical background. This strategy promotes personal understanding, application and retention of key facts, as well as fostering the development of learning and recall as part of the learning experience. The strategy also encouraged the gathering of subject-relevant information and its evaluation, and consequently promoted the application of CCFOs 1, 3, 4, 5 and 7. Collecting, analysing and critically evaluating information therefore becomes an active component of the learning experience and students are expected to use the information provided, engage in and enhance further application. In some instances, formal lectures have been completely eliminated and primarily adopted as an integrated lecture and practical session within a practical setting. The assumption that students have engaged with the lecture material prior to the learning session, provides an expectation that they have some knowledge of the relevant topic. The ideal of students collecting, organising and critically analysing information is a desired outcome during teaching. Thus, the integrated nature of the practical component of this strategy lends itself to the application of various learning resources. Similarly, the integration of discipline-specific content, such as radiological techniques[19] and co-ordinated anatomy and physiology teaching[20] with anatomical teaching, improves the clinical student interest and the application of anatomy.

Team teaching through dissection projects

This strategy allowed the achievement of CCFOs 2, 5 and 6. The dissection experience supports group engagement/peer learning and working effectively with others as team members. Strategies employing the use of body painting were similarly reported to be successful in improving the learning experience for medical students using a team-learning approach.[15] These studies corroborate its value as an adjunct to support the learning of human anatomy. More recently, the construction of anatomical casts was employed to improve the acquisition of anatomical knowledge.[14] These studies have shown to improve the collaborative and problem-solving outcomes necessary to produce professional medical graduates. Thus, the teaching and learning strategy implemented in our study fosters and stimulates self-directed learning through an active (hands-on) approach. Peer learning and the use of team assignments strengthen teamwork

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and improve personal and peer learning through shared accountability. Teamwork is thus enhanced during the practical sessions through the introduction of combined group assessments. This increases student engagement, sharing of knowledge/learning styles and accountability. Moreover, outcomes such as problem-solving and creative thinking are achieved by means of student-directed initiatives to enhance learning, e.g. the use of diagrams, mind-maps, flowcharts and pneumonics. Studies have shown that peer learning encourages the development of collaboration and communication skills and provides a conducive learning community that prepares students for project planning.[21,22] This engagement empowered students to communicate their knowledge and to have it peer reviewed.[21] Furthermore, students become accountable for recognising their own learning needs, thereby ensuring that these needs are met. Peer learning fosters a learning-how-to-learn skill, which prepares students for the co-operative interacting skills necessary to be functional employed citizens.[21] This improves communication and self-confidence.[22] An underlying outcome of the dissection experience, by nature of its team approach and active participation, requires the ability to communicate effectively with each other. Similarly, peer learning and group assessments/ assignments provide a need for peers to communicate effectively and develop effective language skills in written and oral forms. This approach also supports extensive student engagement as a result of their oral delivery with regard to the specific dissected regions to the class. Therefore, the achievement of CCFO 6 was improved owing to the use of various innovative and technological approaches in delivering and communicating the acquired knowledge. The extensive creativity and innovative modes of presentation, such as video recordings, interactive three-dimensional models and posters, were examples of team decisions. Thus, the team dissections and projects provided a medium for the extensive use of science and technology as an adjunct to the conventional use of the e-learning interface.

Conclusion

The value of graduate attributes in HE has gained international recognition, particularly in universities of technology where vocational needs have formed the basis of academic training. The challenge, however, is in trying to integrate qualities such as accountability and shared responsibility into programmes that have traditionally focused solely on self-betterment and professional needs. To our knowledge, this is the first study that presents information of modified teaching methods within the context of human anatomy and in relation to the CCFOs. The teaching methods highlighted in our study attempt to encourage and ensure that students evaluate, understand and apply their knowledge in an integrated and shared manner, as embraced by the CCFOs. We also demonstrated how the application of the theory of reflective practice, coupled with the drive for change by institutional and HE recommendations, can stimulate academics to consider simple ways of applying innovative teaching approaches. Studies that evaluate student perceptions regarding the teaching modifications would further support the reflective practice approach to teaching. A more objective evaluation of the benefits of change (e.g. through assessment performance) would provide useful information and direction for further application. Acknowledgements. The authors wish to thank Mr R Maharaj for his administrative assistance during submission of the manuscript.

Research Author contributions. JDP drafted and conceptualised the article. NG and NL contributed conceptually to the development of the manuscript. All authors approved the final document. Funding. None. Conflicts of interest. None. 1. Council on Higher Education. Work-Integrated Learning: Good Practice Guide. Higher Education Monitor 12. Pretoria: CHE, 2011. 2. South African Qualifications Authority. National policy and criteria for designing and implementing assessment for NQF qualifications and part-qualifications and professional designations in South Africa. 2001. www.saqa. org.za/docs/pol/2015/National%20Policy%20for%20Assessment.pdf (accessed 24 October 2016). 3. Department of Education. Annual Report 2001 - 2002. Pretoria: DoE, 2002. 4. Carmichael T, Stacey A. Perceptions of SAQA’s critical cross-field outcomes as key management metacompetencies. S Afr J Bus Manage 2006;37(2). 5. South African Qualifications Authority. Investigating the use of critical cross-field outcomes in the design of ABET qualifications and unit standards: Terms of reference. Pretoria: SAQA, 2006. 6. Andrews J, Higson H. Graduate employability, ‘soft skills’ versus ‘hard’ business knowledge: A European study. High Educ Eur 2008;33(4):411-422. https://doi.org/10.1080/03797720802522627 7. Alexander CJ, Crescini WM, Juskewitch JE, Lachman N, Pawlina W. Assessing the integration of audience response system technology in teaching of anatomical sciences. Anat Sci Educ 2009;2(4):160-166. https://doi. org/10.1002/ase.99 8. Johnson EO, Charchanti AV, Troupis TG. Modernization of an anatomy class: From conceptualization to implementation. A case for integrated multimodal-multidisciplinary teaching. Anat Sci Educ 2012;5(6):354-366. https://doi.org/10.1002/ase.1296 9. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. 2nd ed. New Jersey, USA: Pearson Education, 2014.

10. Cross V, Liles C, Conduit J, Price P. Linking reflective practice to evidence of competence: A workshop for allied health professionals. Reflect Pract 2004;5(1):3-31. https://doi.org/10.1080/1462394032000169938 11. Postgraduate studies in South Africa – a statistical profile. 2009. http://www.che.ac.za/documents/d000196 (accessed 23 November 2016). 12. Delany C, Golding C. Teaching clinical reasoning by making thinking visible: An action research project with allied health clinical educators. BMC Med Educ 2014;14(1):20. https://doi.org/10.1186/1472-6920-14-20 13. McNiff J, Whitehead J. All You Need To Know About Action Research. London: Sage, 2006. 14. Hermiz DJ, O’Sullivan DJ, Lujan HL, DiCarlo SE. Constructivist learning of anatomy: Gaining knowledge by creating anatomical casts. Anat Sci Educ 2011;4:98-104. https://doi.org/10.1002/ase.206 15. McMenamin PG. Body painting as a tool in clinical anatomy teaching. Anat Sci Educ 2008;1(4):139-144. https:// doi.org/10.1002/ase.32 16. Chang-Seok O, Ji-Young K, Yeon HC. Learning of cross-sectional anatomy using clay models. Anat Sci Educ 2009;2(4):156-159. https://doi.org/10.1002/ase.92 17. Lefroy H, Burdon-Bailey V, Bhangu A, Abrahams P. A novel technique for teaching the brachial plexus. Clin Teach 2011;8(3):196-199. https://doi.org/10.1111/j.1743-498x.2011.00448.x 18. Estai M, Bunt S. Best teaching practices in anatomy education: A critical review. Ann Anat 2016;208:151-157. https:// doi.org/10.1016/j.aanat.2016.02.010 19. Heptonstall NB, Ali T, Mankad K. Medical education in the UK – the evidence, current trends, and future scope. Acad Radiol 2016;23(4):521-526. https://doi.org/10.1016/j.acra.2015.12.010 20. Kageyama I, Yoshimura K, Satoh Y, Nanayakkara CD, Pallegama RW, Iwasaki S. Proposal for research and education: Joint lectures and practicals on central nervous system anatomy and physiology. J Physiol Sci 2016;66(4):283-292. https://doi.org/10.1007/s12576-015-0428-x 21. Boud D, Cohen R, Sampson J. Peer learning and assessment. Assess Eval High Educ 1999;24(4):413-426. https:// doi.org/10.1080/0260293990240405 22. Stone R, Cooper S, Cant R. The value of peer learning in undergraduate nursing education: A systematic review. ISRN Nurs 2013;2013:1-11. https://doi.org/10.1155/2013/930901

Accepted 21 November 2017.

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Research

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

Strengths and challenges of community-based clinical training as viewed by academics at the University of KwaZulu-Natal, Durban, South Africa I Moodley, 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. Community-based education (CBE) is seen as a valuable tool in transforming health professions education by aligning clinical training with graduate competencies and needs of the health system. However, academics involved in the implementation have varied views. Objectives. To explore the experiences and views of academics involved in community-based training in the College of Health Sciences at the University of KwaZulu-Natal, Durban, South Africa. Methods. This qualitative study used interviews and focus group discussions consisting of a purposively selected sample of academics. The interviews were audio taped, transcribed and analysed using thematic analysis. Results. Three main themes emerged from the data analysis: the strengths of CBE, challenges experienced in implementation and academicsâ&#x20AC;&#x2122; suggestions concerning challenges. The strengths included benefits to the institution, students, health system and communities. The main challenges experienced were insufficient support from the institution and the Department of Health (DoH). Suggestions were made by academics to overcome these challenges. Conclusion. The study indicates that CBE is perceived as an important pedagogical approach in transforming health professions education, as it can align clinical training with the business plan of the university and the needs of the health system. However, for the successful implementation of CBE, full support from the university and the DoH is required. Afr J Health Professions Educ 2018;10(2):129-135. DOI:10.7196/AJHPE.2018.v10i2.954

Community-based education (CBE) is a pedagogical approach that allows a student to develop professional skills in a community setting and gain a deeper understanding of patients in varied social and cultural contexts.[1] From the literature, CBE is shown to be beneficial to students in various ways, including improved practical skills and clinical reasoning, increased self-confidence and development of a positive attitude toward patients.[2-5] By experiencing real work situations, students develop a greater awareness of the responsibilities they have as health professionals.[4] Through student placements in community-based settings, CBE is equally beneficial to communities, leading to improved access to healthcare and improved quality of care owing to the use of current practice techniques.[4,6] Communities also benefit through home visits and health promotion activities that students undertake.[4] Health systems have been noted to benefit from CBE, as students are seen to expand the workforce, especially in rural areas, where there is a scarcity of healthcare workers.[6] Moreover, student CBE placements in rural areas have the potential to influence studentsâ&#x20AC;&#x2122; responsiveness to community needs and their future decisions to work in these areas.[4] This can contribute to long-term benefits for the health system. Institutions of higher education that implement CBE programmes are viewed as demonstrating social accountability.[7] Health professions education is undergoing major reform owing to two main external influences: (i) the Council for Higher Education (CHE) that advocates the integration of community engagement into curricula in the South African (SA) context;[8] and (ii) the Lancet Commission that called for health professionals to graduate with appropriate competencies to be fully

functional in a patient- and population-centred health system.[9] Given this context, the University of KwaZulu-Natal (UKZN), Durban, SA strives for reform through its goal of responsible community engagement as outlined in its vision and mission statement. This goal aims to transform health professions education from one with a traditionally structured basis to one with a more competency-based focus that adds value to the communities it serves.[10] To achieve this goal, the College of Health Sciences (CHS) at UKZN embarked on a business plan to adopt a primary healthcare curriculum (PHCC) to address service delivery and health professions training.[11] The business plan proposes that a primary healthcare (PHC) approach be followed for all programmes offered by the CHS.[11] In line with this approach, the CHS seeks to produce socially accountable, competent and relevant healthcare professionals with discipline-specific technical skills and generic higher education competencies and attributes. In this way, graduates become more responsive to provincial and national health priorities, the burden of disease and the health system. The CHS is therefore committed to offering community-based under- and postgraduate education.[11] Community-based clinical training is seen as a valuable tool for transforming health professions education to meet graduate competencies and the needs of the health system.[9] Therefore, to foster these competencies, UKZN creates learning opportunities for health professions students to engage in activities that can enable them to acquire these skills and values in community-based settings. In the literature, there are many studies highlighting studentsâ&#x20AC;&#x2122; experiences and views of CBE, but there is a paucity of

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Research studies on the views of academics directly involved with the implementation of CBE. The objective of this study is to present the experiences and views of academics currently implementing community-based training in the CHS, UKZN.

Methods

Research setting and context

The CHS, UKZN comprises four schools: Clinical Medicine, Laboratory Medicine and Medical Sciences, Nursing and Public Health, and Health Sciences. The School of Health Sciences has eight disciplines: audiology, biokinetics, exercise and leisure sciences, dentistry, occupational therapy, optometry, pharmaceutical sciences, physiotherapy and speech-language pathology. Clinical training in these disciplines is done at campus clinics and designated off-campus sites. CBE is a prominent feature across all disciplines, but the level of participation differs. Moreover, as part of the business plan, disciplines are expected to send students to decentralised training sites, i.e. regional and district hospitals and community healthcare centres around these hospitals.

Research design

This was a descriptive, qualitative explorative study in which the intended role of community-based clinical training in the CHS was explored and the views of academics involved with CBE were described.

Participants

A purposive sampling method was used to select the study sample. The participants selected for the interviews included the college dean of teaching and learning, the academic leader of teaching and learning and the head of the Department of Family Medicine/Rural Medicine. They were selected for

their expert opinion. One academic from each discipline in the School of Health Sciences was purposively selected for the focus group discussions. The researcher (IM) sent an invitational email to each participant. A total of 11 participants (A1 - A11) gave written informed consent to participate in the study.

Data collection

Data were collected by using a combination of interviews and focus group discussions. Firstly, the researcher conducted in-depth individual interviews with the dean and academic leader to gain a better understanding of the role of CBE and how it should be rolled out at discipline level. The researcher developed a set of leading questions to provide a relevant structure to the interviews (Table 1). The interviews focused on the policies and procedures for implementing CBE, support and mechanisms for CBE and funding. Secondly, a separate face-to-face interview was held with an academic from the School of Clinical Medicine (the head of the Department of Family Medicine/Rural Medicine). The purpose of this interview was to obtain a better understanding of CBE experiences in other schools within the CHS. The interviews were scheduled at the intervieweesâ&#x20AC;&#x2122; convenience and lasted ~30 minutes. Lastly, the researcher facilitated focus group discussions with academics representing each discipline. As all academics were not available simultaneously, two focus group discussions were held. The researcher developed a set of open-ended questions to guide the focus group discussions (Table 2). The discussions were related to their current CBE projects and how these added value to their clinical training practice, as well as the challenges experienced with implementation. The focus group discussions lasted ~65 minutes. The researcher audio taped the interviews and focus group discussions. A research assistant transcribed the recordings verbatim and then performed

Table 1. Interviews with the dean and academic leader Interview with dean What is your view of community-based clinical training in the education process of health professionals within the School of Health Sciences? In your opinion, how will this add value to current teaching strategies for clinical training in terms of meeting graduate competencies and meeting needs of the health system? What policies and procedures are in place for community-based clinical training? What mechanisms and support can the school provide for community-based clinical training? How will community-based clinical training be funded?

Interview with academic leader What is your view of community-based clinical training in the education process of health professionals within the School of Health Sciences? In your opinion, how will this add value to current teaching strategies for clinical training in terms of meeting graduate competencies and needs of the health system? What is the strategic operational plan present/envisioned by the School regarding community-based training of health professionals? How can disciplines within the school align to this plan? How should community-based training be integrated into the current curriculum?

Table 2. Focus group discussions with academics Kindly share your thoughts on the universityâ&#x20AC;&#x2122;s goal of community engagement and community-based education for health sciences students. What are your views of how this can be implemented at discipline-specific level? What is the current practice of community-based training in your discipline? In your view, how does community-based teaching and learning add value to your current clinical training strategies? In your opinion, how can community-based clinical training align with the primary health care curriculum model that aims to address service delivery and training of healthcare professionals? In your view, how can community-based teaching align with the health professional graduate attributes in the various roles of healthcare practitioner, who is compassionate and culturally sensitive, communicator, collaborator, leader, scholar and advocator as envisioned by the College of Health Sciences? From your experience, what are some of the challenges experienced in implementing community-based training?

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Research a data clean-up process. The researcher engaged the services of a research consultant to assist with the data analysis process. This consisted of data coding to identify particular features of the data set and sorting of the data, allowing themes and sub-themes to emerge from the respondents’ statements according to Braun and Clarke’s[12] guide to thematic analysis. Credibility was established by the use of varied research methods, i.e. interviews and focus group discussions to obtain the data as well as peer debriefing. Another member of the research team conducted the peer debriefing by examining the data collection methods, processes, transcripts and data analysis procedures, and provided guidance to enhance the quality of the research findings.[13] Transferability was facilitated by detailed description of the enquiry and purposive sampling.[14] Transferability was further enhanced by comparing research findings with the current literature. Dependability was achieved by the use of a co-coder (research consultant) and confirmability was established through the direct quotation of interviewees. Participant confidentiality and anonymity were maintained.

Ethical approval

This study was part of a larger study conducted on CBE in the School of Health Sciences. Ethical clearance was obtained from the Humanities and Social Sciences Research Committee, UKZN (ref. no. HSS/1060/015D).

Results and discussion

Based on the responses of participants in the interviews and focus group discussions, three main themes emerged from the data analysis process: strengths of the community-based clinical training, challenges experienced and suggestions by academics.

Strengths of community-based education

This study revealed that academics viewed CBE as beneficial at multiple levels. The following section contains a selection of illustrative quotations of the benefits of community-based clinical training. The quotes are displayed on an institutional, student, health system and community level. Benefits to institution An academic reported that through CBE the institution could achieve its goal of responsible community engagement by producing socially accountable health professionals. It could create a platform for the institution to implement its policies and teaching strategies, as illustrated by the quotes in Table 3.

Related to its mission and vision statement, UKZN set out goals of being an academic institution actively engaged in redressing the disadvantages and imbalances of the past.[10] The goal of responsible community engagement can be driven through CBE initiatives. By integrating CBE into the curriculum, the university is showing social accountability. This can contribute to the upliftment of the province by producing socially accountable health professionals and serving under-resourced communities. The literature also shows that higher education institutions with a socially accountable mandate can have a positive influence – not only on students but also on surrounding disadvantaged communities, leading to better health outcomes.[15] Through implementation of policies and teaching strategies related to CBE, the institution can be seen as facilitating the transition of traditional approaches of teaching to competency-based approaches that align training with the health needs of communities and the health system.[9] Benefits to students Academics believed that CBE could allow students to develop professionally. Students could improve clinical skills, proficiency and critical reasoning by being exposed to many patients. They could also learn by working closely with experienced colleagues in different clinical settings. At a deeper level, it could help them to relate theory to practice and acquire graduate competencies, such as compassion, better communication and leadership skills. These skills are not necessarily obtained in the classroom (Table 4). It is well documented in the literature that CBE has been shown to enhance students’ self-development, improving competence and confidence levels through increased patient exposure in community settings.[1] Graduate competency can be defined as the acquisition and application of knowledge, clinical skills and values to provide effective care to patients.[11] This study showed that CBE could create learning opportunities for students to acquire these attributes. These findings were similar to those of Mabuza et al.,[16] who indicated that the main focus of CBE was the learning of practical skills, professional behaviour and relating theory to practice. However, Ferris and O’Flynn[17] argue that for CBE to be more meaningful, students should not be left at these sites to acquire practical skills only; they should be given opportunities to self-reflect and self-assess, which can contribute to lifelong learning. Benefits to the health system According to academics, the health system could also be strengthened through CBE initiatives. Benefits included building sustainable partner

Table 3. Benefits to the institution Benefits Meaningful community engagement

Implementation of policies

Facilitating implementation of various teaching strategies

Participants’ quotes ‘We are trying to train competent, relevant, socially accountable health professionals. What better way than to let them go into the community… So we are giving back as a university and, as existing and potential healthcare professionals equally, we are gaining by being trained and fulfilling our criteria for our degree to practise as healthcare professionals.’ (A1) ‘It allows us to implement the policy frameworks of the Department of Health provincially, as well as nationally, and it allows us as a college to really give effect to our own vision and mission whether it is the Teaching and Learning Office and teaching and learning related to research to general university vision and mission and goals. I think we are in the right place at the right time.’ (A1) ‘Community-based training requires a certain type of pedagogy of interactive participative learning. There are frameworks and pedagogies that have been implemented in different programmes … but I think we have got some excellent examples of good practice that we can learn from each other and implement.’ (A1)

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Research ships, making healthcare more accessible to communities and aligning health professionals’ training with the needs of the health system, which could make them easily employable (Table 5). By collaborating with the Department of Health (DoH), a mutually beneficial relationship can be developed. The university will benefit, as their clinical training platforms could be significantly expanded. The DoH will benefit, as students could complement the current workforce in under-resourced areas, improving access to healthcare. This is further supported by Mabuza et al.[17] – students are viewed as important members of the health team and appreciated and welcomed by communities.

Students exposed to CBE in rural areas could gain better insight to inequalities of healthcare and be motivated to return to these areas to seek employment. A study by Kaye[6] shows that community-based clinical training changes students’ attitudes towards rural practice and plays an important role in influencing graduates to work in underserved areas. Furthermore, students could have first-hand experience of how the health systems operate, facilitating their transition to the work environment. This finding is further supported by Knight,[18] who found that students gained a better understanding of the policies and politics of clinics while in training.

Table 4. Benefits to students Benefits Improving clinical skills Acquiring critical reasoning Learning from mentors Adapting to different work environment Relating theory to practice Applying primary healthcare principles Providing appropriate care

Achieving non-technical competencies

Opportunities for postgraduate studies

Participants’ quotes ‘Our students get to attend to more patients in the same time they attend to one patient at the clinical training site.’ (A6) ‘They also do not come in with a ready-made diagnosis … Here they just have to think on their feet and problem solve on site.’ (A5) ‘They are also exposed to different supervisors with their own clinical expertise.’ (A6) ‘Working within the communities prepare the students for when they qualified … they learn to work with what they have available.’ (A6) ‘The students will provide a service that they have already demonstrated theoretically that they have the knowledge and through the provision of the service they will develop the clinical competencies.’ (A4) ‘Students do a lot of broad-base promotive and preventive work throughout the communities.’ (A7) ‘… it is also looking at what is relevant and appropriate for this context, not only socioeconomically but geographically. There is a focus on bringing in the family and the broader community where possible. Where there is somebody isolated at home, the rehab is focusing on the families sometimes, even the neighbours or community caregivers and using the resources that are in the community.’ (A4) ‘It is kind of startling to realise that the patient is a person who has a family and if they understand where the patient comes from they will treat them completely differently. There is a potential for a much deeper, nearly like an ontological shift that takes place.’ (A3) ‘… it is also adding value in terms of the non-clinical aspects. All those things like teaching them how to be leaders in an under-resourced environment, to communicate better when there is a language divide. We find that the campus-based, more resourced training environments were just letting them think in that sort of clinical, mechanical fashion, but now they are forced to be able to apply other skills in that context.’ (A8) ‘I do not think the university sufficiently teaches these competencies or tries to shift thinking in any way possible, we just want to get through the content of the curriculum. This is the right environment where we shift their thinking, where we mould them into what we would like them to be.’ (A5) ‘There are some postgrad projects at Master’s and PhD levels where research is done in communities.’ (A11)

Table 5. Benefits to the health system Benefits Building sustainable partnerships

Participants’ quotes ‘The business plan of community-based training and the primary healthcare model was developed in conjunction with the provincial Department of Health so it has the endorsement and support from key role players in terms of implementing it. So we will have the clinical training platforms with the department and hopefully we will have the staff to assist us in doing that.’ (A1) Making healthcare more accessible ‘The focus is ideally on taking rehab services into the underserved. For example, for a mum with cerebral palsy child … She might only get therapy once a month … she might have to make two taxi trips to get there [local hospital]. If she is taking her child, that will be two taxi fares and if he is on a wheelchair that is a third fare. It is not about not having access, it is about the reality of that access … .’ (A4) Learning how the health system operates ‘They are actively going out and we have made an attempt to get them right down to clinic level and not just hospital level, so they understand how the health system works right from the start.’ (A8) Producing work-ready graduates ‘… with community-based training, we are trying to implement the policy frameworks and train our students such that they are capable of working in the primary healthcare environment equally well as they will be working in tertiary services for them to be proficient across the continuum.’ (A1)

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Research Benefits to communities Our study revealed that communities could benefit greatly from CBE initiatives. Most disciplines chose underserved communities to undertake their projects to provide or improve access and affordability to healthcare services (Table 6). Our findings of benefits to communities were similar to those of Diab and Flack,[4] who found that the primary benefit to communities was improved service delivery. By living in communities, students can become immersed with the realities of the communities.[7] They can develop a better understanding of the disease burden and the social and cultural aspects that impact on health. Kelly et al.[5] supported this finding that learning is developed by rich relationships with community members. Doherty and Couper[7] indicated that through interaction with patient, family and community, students learn by exposure to an integrated primary healthcare experience. However, Diab and Flack[4] argued that communities receive maximum benefits if the CBE initiatives are aligned with community needs. They also showed that it is important to engage community leaders before student placements to explain their function, as communities feel undermined if not informed of students’ presence.

Challenges

This study shows that although academics embraced the pedagogical approach of community-based clinical training, they experienced challenges that could hinder implementation. The following section contains a selection of illustrative quotations of the challenges of community-based clinical training. The quotes below relate to challenges at university and DoH levels. Challenges at the university The challenges at the university included not having a clear operational plan, co-operation of all academics, support from the university and logistical issues. No clear operational plan. At the university, the organisational structures are three-tiered: the college level, school level and discipline level. Although the business plan was being rolled out at college level, there seemed to be no clear operational plans or communication on how this had to be filtered down to individual disciplines in the school. While academics from individual disciplines believed that there should have been direction from college and school levels, academics from these levels believed that it should be driven by academics in individual disciplines, as illustrated by the following conflicting quotes: ‘This clinical training model was conceptualised, and while it was good and we all supported it on theory, there was no situational analysis, … no

plan as to how we are going to roll it out based on the situational analysis; we cannot just say we have this plan … the DoH needs help where our students get exposed. Let us just go and do it.’ (A8) Academics from college and school level firmly believed that: ‘It is people from the ground, from various disciplines who are very passionate about this and who are committed people who will investigate it thoroughly, come out strategically, logistically, resourcefully draw up their own mandates with their own roles and responsibilities. So it is more bottom up. It will never be top down. It will be you having to push from the bottom and finding the ways of making things happen.’ (A1) Co-operation of all academics. Academics who represented individual disciplines in the focus group discussions believed that they were the only ones in their respective disciplines who were responsible for CBE. Other staff members seemed disinterested and if they were to leave, the CBE initiatives would fall apart: ‘If I go, the project from my discipline will fall apart, that is unfortunate. We have become the face of the community … if there is not a voice to speak for it, it falls apart because it is not entrenched in the curriculum. It is hard work and it is time consuming – that is why nobody wants to do it.’ (A4) Support from the university. There seemed to be a mismatch between the support given by the college and that received by academics. While academics at college and school level endorsed and supported CBE, academics involved in implementation thought otherwise: ‘There needs to be supporting structures in place as much as they are saying the community outreach should have things in place for us, because lots of things we start and have to stop because of resources, etc.’ (A4) The study also highlighted that there were no incentives for staff participating in community engagement: ‘Do we get rewarded for community engagement? Is there any structure for community engagement? We have got a research office; we have got a teaching and learning office. Is there an office for community engagement? ... it needs to be taken seriously.’ (A3) Logistical issues. The results of the study showed that many challenges were logistical in nature, including funding, limiting timetables, CBE being timeconsuming and community issues:

Table 6. Benefits to the community Benefits Improving service delivery Committing to sustainable services

Promoting health in the communities Interacting with communities

Participants’ quotes ‘The priority is to offer a service to the underserved … focus particularly on people, children largely with disability, who either are unable to or have enormous challenges accessing the services that are available.’ (A4) ‘It is important that we need continuity in a community. If you start providing a service, you must commit to it. We cannot use the community only to take the students there, they start something and then we take them out. It is also not fair to the community.’ (A2) ‘Students engage directly with the community, determine their needs and do promotive and preventive work outside of the clinic base.’ (A7) ‘With the community home-stay project where for the rural block we offer some students to live in the community … students engage with host mothers … they are quite motherly.’ (A3)

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Research Funding ‘We have costs to consider when going out to communities. The main reasons we were pulled out of a very effective and established project was the cost to transport the students.’ (A4) ‘Even with us, the consumables that we require, the cost factor. A lot of our projects have a problem to sustain themselves because we do not have resources.’ (A6) Timetables ‘We have a university timetable that does not allow for an integration of disciplines.’ (A4) Time consuming ‘I had a student 2 weeks ago who wanted to go and do a follow-up assess ment on a child. She cannot do that independently and the home visit is way into the community. The time now for me to go and observe and check on her means a whole morning.’ (A4) Community, political and safety issues ‘We had followed everything in the book, the gatekeeper introduced us to everyone and the next thing, we got kicked out from our placement site which was a high school because of the political nature of the community. They thought we were aligned to someone who they were in conflict with. It was the gatekeeper himself. Although we were independent from him and he introduced us, but we got parcelled with him … .’ (A7) Challenges at the university stem mainly from a lack of support from school and college level: support in the sense of effective communication down to discipline level, guidelines on how CBE programmes should be implemented, expectations and roles of academic staff and financial support. These challenges are not unique to this institution – similar challenges were noted in previous studies, with the main challenges being leadership support, funding and academics not willing to participate in the programme.[19] Doherty and Couper[7] found that CBE programmes are complex and time-consuming and require sustained hard work by committed academics. CBE is viewed as a mechanism for the university to demonstrate social accountability. The university should therefore provide the structure and support for successful implementation of this programme. It should also be supported by more academics within disciplines – not only those who have an interest in CBE. Challenges with the Department of Health The challenges experienced with the DoH were mainly due to clinical staff not clearly understanding their role in community-based training of students or not being aware of it. Academics were dependent on DoH staff for supervision of students, monitoring their attendance and writing reports on them at decentralised sites. However, there appears to be a lack of commitment from some clinical staff, and students were sometimes seen as a burden and impeding their work: ‘There are perceptions from the DoH that this is an outside programme or an outside responsibility that is being imposed on them. There was no plan that was filtered down to the ground. There was this memorandum of understanding between the DoH and UKZN, but the people on the ground are not really aware of it.’ (A8)

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‘ We made arrangements with the head of department to supervise our students. He was very enthusiastic; however, other personnel were not so eager to supervise, as they felt that students slowed down their work pace.’ (A6) The challenges with the DoH were similar to those of the university in the sense of not having any guidance from higher authorities. This lack of support for clinical staff can be viewed as a missed opportunity for shared responsibility of this programme. This can hinder student learning at DoH sites, as it has been shown that staff enthusiasm for student supervision enhances student learning.[16] It is important for academic staff to provide support for clinical staff in orientation and training of student supervision, as Archer[20] noted that clinical supervisors changed their perceptions about student supervision after a short course designed by the university.

Suggestions by academics

The study revealed that academics viewed CBE as being extremely valuable and were eager to make it work, despite many challenges. The following are illustrative quotations of solutions they offered: No clear operational plan ‘There needs to be a core team. We need to sit together and come up with objectives for CBE training; this is the output and this is what we expect of the staff and students.’ ‘Without leadership, there is nobody steering the ship. Leadership is critical to develop or put together this framework so we can roll out this community-based teaching they expect from us.’ (A10) Challenges with DoH ‘The one solution that we had was train the trainer. We bring all the clinical staff into the university, we get a workshop going and then we do programmes with them and then we do sessions at the end, where we get them to watch. We were thinking of getting videos and getting them to watch and assess so there is inter-reliability.’ (A10) ‘Maybe those trainers should be given some sort of honorary appointment or incentive for them being involved in the training of our students because they will tell you that look, I have queues to push … .’ (A9) Communication issues ‘There should also be good, open communication within the institutions and between the institutions, especially with the people on the ground who are directly involved with CBE programmes.’ (A6) This study shows that academics have the enthusiasm to drive the community-based clinical training agenda. SA health professions education is transforming[17] and CBE is certainly a mechanism of change toward this transformation in making clinical training more meaningful in the SA context. Transformation is an ongoing process and academics should seize the opportunity for academic autonomy and control over CBE, as it has been shown to have great value in the education process of students in the health sciences. This is further supported by Doherty and Couper,[7] who state that CBE programmes should be driven by champions within disciplines, especially if there is resistance from other staff. While there are committed academics from the institution, there should also be committed

Research health professionals from the DoH supervising students at the teaching sites. CBE should be regarded as a shared responsibility of the collaborating institutions to ensure success and sustainability.

Study limitations

It is acknowledged that this study is limited to only one university and that the findings related to the views and opinions of academics who participated in the study are limited owing to their generalisability. Therefore, more research is required at other universities in SA to obtain wider, broad-based opinions of academics regarding CBE.

Conclusion

The study indicates that CBE is perceived as an important pedagogical approach in transforming health professions education, as it can align clinical training with the business plan of the institution and the needs of the health system. Academics play a pivotal role and are seen as drivers of CBE. However, for the successful implementation of CBE, there needs to be full support from the university and DoH to overcome any challenges that may arise. 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. Skelton J, Raynor MR, Kaplan AL, et al. University of Kentucky community-based field experience: Program description. J Dent Educ 2001;65:1238-1242.

2. Eaton KA, de Vries J, Widstrom E, et al. ‘Schools without walls?’ Developments and challenges in dental outreach teaching – report of a recent symposium. Eur J Dent Educ 2006;10(4):186-191. https://doi.org/10.1111/j.1600-05 79.2006.00411.x 3. Piskorowski WA, Stefanac S, Fitzgerald M, Green TG, Krell R. Influence of community-based dental education on dental students’ preparation and intent to treat underserved populations. Dent Educ 2012;76:534-539. 4. Diab P, Flack P. Benefits of community-based education to the community in Southern African health science facilities. Afr J Prim Health Care Fam Med 2013;5(1). https://doi.org/10.4102/phcfm.5i1.474 5. Kelly L,Walters L, Rosenthal D. Medical education: Is success a result of meaningful personal learning experiences? Educ Health 2014;27(1):47-50. https://doi.org/10.4103/1357-6283.134311 6. Kaye DK, Mwanika A, Sewankombo N. Influence of the training experience of Makerere University medical and nursing graduates on willingness and competence to work in rural health facilities. Rural Remote Health 2010;10:1372. 7. Doherty JE, Couper I. Strengthening rural health placement for medical students: Lessons for South Africa from international experiences. S Afr Med J 2016;6(5):524-527. https://doi.org/10.7196/SAMJ./2016.v106i5 8. Centre for Higher Education, Higher Education Quality Committee, South Africa. Criteria for Institutional Audits. Pretoria: CHW, 2004. 9. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376(9756):1923-1958. https://doi.org/10.1016/s01406736(10)61854-5 10. University of KwaZulu-Natal. Vision and mission statement. Durban, South Africa. http://www.ukzn.ac.za (accessed 13 April 2018). 11. Essack S. Draft business plan: Community based training in primary health care model in School of Health Science. Durban: UKZN, 2014. 12. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77-101. https:/doi. org/10.1191/1478088706qp063oa 13. Pitney WA, Parker J. Qualitative Research in Physical Activity and the Health Professions. Auckland, New Zealand: Human Kinetics, 2009. 14. Bitsch V. Qualitative research: A grounded theory example and evaluation criteria. J Agribus 2005;23(1):75-91. 15. Reeve C, Woolley T, Ross SJ, et al. The impact of socially-accountable health professional education: A systematic review of the literature. Med Teach 2017;39(1):67-73. https://doi.org/10.1080/0142159X.2016.1231914 16. Mabuza LH, Diab P, Reid SJ, et al. Communities’ views, attitudes and recommendations on community-based education of undergraduate health sciences students in South Africa: A qualitative study. Afr J Prim Health Care Fam Med 2013;5(1). https://doi.org/10.4102/phcfm.v5i1.456 17. Ferris H, O’Flynn D. Assessment in medical education. What are we trying to achieve? Intern J High Educ 2015;4(2):139-144. https://doi.org/10.5430/ijhe.v4n2p139 18. Knight GW. Community-based dental education of University of Illinois, Chicago. J Dent Educ 2011;75(10) (Suppl):S14-S20. 19. 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;6(6):444-451. https://doi.org/10.3109/13561820.2012.715604 20. Archer E. Improving undergraduate clinical supervision in a South African context. Afr J Health Professions Educ 2011;3(2):6-8.

Accepted 5 October 2017.

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Research

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

A support programme for registered nurses in the early identification of autism spectrum disorders in primary healthcare clinics: A pilot study A-M Wium, DPhil (Commun Pathol); M de Jongh, PhD (Psychol) Department of Speech-Language Pathology and Audiology, School of Health Sciences, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa Corresponding author: M de Jongh (marguerite.dejongh@smu.ac.za)

Background. Registered nurses in South Africa often work in community clinics in primary healthcare (PHC), where they are first in line to be consulted by families with children with disabilities. There has been limited research with a focus on interprofessional collaboration regarding autism spectrum disorders (ASDs) in the local context. A support programme was developed to inform registered nurses in PHC of the symptoms and characteristics of ASDs in order to increase the number of referrals to specialists for early diagnosis. Objectives. To determine the effectiveness of a support programme for registered nurses in PHC clinics, and to raise awareness of ASDs. Methods. Two PHC clinics in a semirural area in Gauteng Province, SA, were included in the study, in which 10 registered nurses participated. A descriptive, quantitative approach was used, and data were collected by means of self-administered questionnaires. Results. The results confirmed that the support was effective, as participants showed an increase in knowledge and understanding of ASDs. Poor attendance and the limited sample size affected the outcomes. Conclusion. A multidisciplinary approach to the early identification and referral of children with possible ASDs is important to improve the quality of life of these children and prevent further delays. Speech-language therapists should provide support to registered nurses in PHC, and training should be repeated on a continual basis to facilitate long-term retention and to accommodate shift changes within clinics. Afr J Health Professions Educ 2018;10(2):136-140. DOI:10.7196/AJHPE.2018.v10i2.963

Autism spectrum disorders (ASDs) encompass a wide spectrum of symptoms and levels of impairment in the social, communicative and behavioural domains.[1] There has been limited research with a focus on interprofessional collaboration regarding ASDs in the local context. The intention of the present research was to develop a support programme that would allow registered nurses in primary healthcare (PHC) to identify the characteristics of children with ASDs and to recognise possible risk factors. This practice would allow nurses to refer such children to appropriate healthcare services, and to provide parents with essential information when there is reason for concern. PHC is the first level of contact between the general population and the health system.[2] Patients are referred to healthcare services at secondary and tertiary hospitals.[3] Nurses in PHC often have to consult with the families of children with disabilities.[4] As registered nurses interact with mothers about the welfare of their children, and become aware of their concerns, they require unique knowledge, competencies and skills.[3] It is therefore important that nurses in PHC are made aware of the characteristics and risk factors associated with ASDs (e.g. social, communicative and behavioural problems, and learning characteristics) in order for them to refer children as soon as possible.[5] Early diagnosis provides an opportunity for early intervention, which improves the prognosis of the child in terms of linguistic, cognitive, social and motor abilities.[6] In rural contexts, ASDs are often only diagnosed many years after the onset of symptoms, or misdiagnosed, possibly as a result of a lack of knowledge.[7]

Awareness and knowledge of autism is very limited among healthcare workers in sub-Saharan African countries;[6] early diagnosis and intervention occur more often in developed countries.[8] Because of this situation, the diagnosis and detection of ASDs often occurs too late. Valuable time is lost in which intervention and education could have occurred. In some African countries, the proportion of children with ASDs receiving an education can be as low as 1 - 3%.[9] Early identification is crucial for the development, education and functioning of the child, and should occur before the age of 3.[10] Registered nurses in PHC clinics spend most of their time treating and diagnosing common childhood diseases (e.g. diarrhoea, nutritional deficits, HIV/AIDS) that are related to the national burdens of disease, and are less focused on behavioural difficulties in young children.[3] In addition, registered nurses receive limited information on the topic of ASDs in their professional training. Lack of knowledge about ASDs presents barriers to early identification of and intervention for such children.[5] Previous research has shown that there is a critical need to train healthcare workers in recognising ASDs, especially in underserved communities.[7,11] Early intervention can significantly improve the quality of life of children with ASDs[3] and prevent further delays.[10] Registered nurses should be supported in order to become familiar with the characteristics and risk factors associated with ASDs, and to understand the impact of ASDs on children and their families. Signs of ASDs often appear at the age of 12 - 18 months.[12] Children are usually seen at clinics at regular intervals (6, 12, 18, 24 and 30 months) for immunisation, and on such occasions parents may want to discuss their concerns with the nurse. It is important that registered

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Research nurses at clinics are aware of the characteristics of ASDs and the possible risk factors, so that they can refer a child with suspected ASD to a specialist physician for early diagnosis and intervention.[12,13] A comprehensive diagnostic evaluation of ASDs involves a multidisciplinary team comprised of a paediatric nurse, psychiatrist, psychologist, neurologist, speech-language therapist and occupational therapist. [14] In reality, many children with ASD are diagnosed too late to obtain optimum benefit from early intervention services. It is estimated that <50% of children with ASDs are diagnosed before the age of 3 - 6 years, and that black children are diagnosed much later than white children.[7] This might be a result of inadequate screening practices, slow responses to parental concerns, or a failure to recognise symptoms early in life. The findings suggest that there may be differences in recognition of symptoms and diagnosis across racial and ethnic groups. It may also be a result of differences in accessing information about ASDs and lack of continuity in the provision of healthcare services. In the South African (SA) context, these differences might be attributable to geography rather than simply race, because of a history of racial segregation. The Legislative Blue Ribbon Commission on Autism revealed that in general, children with ASDs might also experience a 13-month delay between the initial evaluation and actual diagnosis.[15] When parents of a child with ASD consult a registered nurse at a PHC clinic, they expect answers to their questions on how to manage their child. Suitable guidance would allow both the family and the child the best quality of life.[14] Early intervention through the use of screening, psychological support and education on ASDs can enable the family to cope and adjust to the necessary changes related to the child’s diagnosis.[16] The present study focused on training registered nurses in PHC clinics in a semirural context on ASD in children.

(i) the training process, and (ii) the knowledge gained about ASDs. The study was designed as intervention research (Fig. 1), using a quantitative approach with a pretest post-test design in the evaluation phase. A questionnaire designed for the study purposes was used, which consisted of mostly closed-ended questions, expanded on by a limited number of open-ended questions. The pre-test questionnaire also included questions about demographic information. The questionnaires collected information on the participants’ knowledge of ASDs pre- and post-training, to determine the effectiveness of the support provided. The workshops were evaluated on a rating scale from 1 - 4. The content and clarity of the questions as well as the face validity in the questionnaires was confirmed prior to the study by obtaining the opinions of three volunteers in the nursing department who were experts in the field of PHC. A pilot study was conducted with three registered nurses at a clinic that was not included in the study, to test the training and instructions. Bias was minimised by not asking sensitive questions of a personal nature, and numbering the questionnaires to ensure anonymity. The questions were based on findings from the literature review and the objectives of the study. Ethical clearance for the research was obtained from Sefako Makgatho Health Sciences University’s Research and Ethics Committee (ref. Needs assessment

137

Assess effect (referral rate) Assess effectiveness

I. Problem analysis and project planning

Methods

Two PHC clinics in a semirural area in Gauteng Province, SA, were included in the study, and 10 registered nurses participated. In this specific context, referrals are made from primary to tertiary level, as there are no secondary hospitals in close proximity to the clinics. The aim of the study was to determine the effectiveness of the support provided in terms of

no. MREC/H/78/2012: UG), and the Gauteng Department of Health. All ethical principles were adhered to in the design of the study. The researchers conducted a briefing session at the two clinics to explain the rationale for the study and what would be expected from the participants, before obtaining informed consent. Arrangements were made for the training sessions. The Gauteng Department of Health determined the particular dates for training in accordance with their continuing professional development schedule. The workshops were designed according to adult learning principles, and were facilitated by the researchers. The participants were registered nurses with a 4-year qualification, who had not obtained any additional specialised qualification (e.g. in psychiatry or paediatrics). The two PHC clinics were purposively selected as they were at a reasonable distance from the tertiary institution. The two training sessions of 1 hour each were scheduled over 2 consecutive weeks at each of the clinics. The first session focused on defining and describing the characteristics, prevalence and causes of ASDs, as well as associated risk factors. The second addressed the role of registered nurses in the identification of ASDs, parent education and the available resources for children with ASDs. Although a large number of registered nurses (n=21) initially provided informed consent to

II. Information gathering and synthesis

III. Design

V. Evaluation and advanced development

Identify and involve role players

Use existing information sources

Design an observational system

Develop prototype

Design the research methodology

Gain entry and co-operation from settings

Study natural examples

Specify procedural elements of training

Conduct pilot test

Collect and analyse data

Identify population's concerns

Identify key elements of successful models

Apply design criteria to preliminary programme

Replicate programme under field conditions

Analyse concerns identified

Set goals and objectives

Fig. 1. Framework for intervention research.[17]

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IV. Early development and pilot testing

Refine the programme

VI. Disseminate information

Research participate in the research at the initial briefing sessions and attended at least one of the workshops, only those who attended both workshops and completed both the questionnaires were included in the research (N=10). The high attrition rate (52%) was due to shift changes and availability on the prearranged days of the workshops. The researchers, who were independent from the clinics, distributed and collected the questionnaires by hand. Baseline knowledge had been determined by completing the questionnaire prior to the workshops, and was then compared with the post-training results to obtain knowledge gains. Following each workshop, the participants rated the presentation. The quantitative data were entered into an Excel (Microsoft, USA) spreadsheet to be analysed descriptively. Results are presented as percentages (Table 1). Qualitative answers were listed in a table format and quantified on a threepoint scale as either correct (2), partially correct (1), or incorrect (0), according to a memorandum. Knowledge gains were based on a comparison between pre-and post-training scores.

could explain the concept of ASD to some extent prior to training, while all (100%) could do so after training. There is, however, room for improvement and a need for further training, as 70% could still only partially explain what ASD entails (Table 2)[13] following training. Such results imply an emergent understanding of the concept. The ideal would be to provide the participants with additional support, to generate a full understanding of the concept by all the participants. There appears to have been an increase in the level of understanding of specific problems associated with autism, as 90% of the participants had only limited knowledge pre-training (partially correct or incorrect responses), in contrast to 50% post-training, though this still leaves room for improvement. Similar knowledge gains can be seen in participants’ understanding of the age at which autism appears, as only 50% of the participants described it correctly prior to the support provided, in contrast to 90% after the training. ASDs appear during the first 36 months of life,[5]

100

Results

90 80 Participant response, %

The effectiveness of the support provided was determined by participants’ ratings of the length of the presentation, the language used, the preparedness of the presenters, the style and format of the presentations and the value of the support provided. The majority (90%) regarded the length of the workshops (1 hour) as being adequate. All the participants (N=10) viewed the language used to conduct the workshops as adequate and easy to understand. The presentations were conducted in an explanatory manner in English, which is the language of higher education and training in SA.[20] All the participants (N=10) considered the researchers to have been adequately prepared for the workshops. The style and format of the presentations were considered to be ‘interesting’ by all the participants. The workshop format, using PowerPoint (Microsoft, USA) together with discussions, appealed to the participants. These results confirm that the presentations and information were valued and interesting, because the content was new but relevant to the participants. The participants also asked several questions and made comments that elicited discussion during the presentations. Fig. 2 shows participants’ perceptions of benefits obtained from the training. Of those participants who gained (100%) in knowledge, 90% indicated that they gained significantly. These results were confirmed by comparing the pre- and post-training questionnaires (Table 1). This comparison showed definite gains in knowledge, as only 50% (n=5) of participants

70 60 50 40 30 20 10

10 0

ain

g No

ain

dg ite

Lim

ific

n Sig

t en

tg an

m om oc

Knowledge increase Fig. 2. Participant rating of benefits of the presentation (N=10).

Table 1. Comparison of pre- and post-training knowledge/understanding of autism spectrum disorders (N=10)

What do you consider autism to be? Autism is characterised by specific problems. Please list. At what age does autism usually appear? What are the educational alternatives/options for a child with autism? Which other problems can be associated with autism? Is autism hereditary? Who is responsible for the diagnosis of autism? What are the causes of autism? Where do you refer a child when you suspect an autism spectrum disorder? What are the treatment approaches for a child with an autism spectrum disorder?

Pre-test questionnaire answers, % Partially Correct correct Incorrect 0 50 50 10 50 40 40 10 50 40 0 60 20 20 60 40 30 30 10 70 20 30 20 50 0 80 20 10 20 70

Post-test questionnaire answers, % Partially Correct correct Incorrect 30 70 0 50 40 10 90 0 10 50 0 50 60 30 10 50 20 30 40 50 10 70 30 0 90 0 10 50 10 40

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Research Table 2. Characteristics of autism spectrum disorders[12] Social characteristics Poor pretend play skills Poor eye contact Inappropriate display of emotions Limited interest in social interaction Inability to understand gestures, social cues and facial expressions

Communication characteristics Difficulty reading and expressing emotions Inability to babble or coo Language delay Echolalia Limited imitation Difficulty using gestures and facial expression and understanding social language Limited vocabulary Inadequate use of grammatical structures, intonation, pitch, rhythm and stress Short attention span Disorganised

and it is during this period that parents usually consult PHC clinics and express their concerns. Registered nurses should be vigilant and able to identify the risk factors and symptoms of ASDs, which include social, communicative and learning characteristics, as well as behavioural problems.[5] There was also an increase in the proportion of participants (30%) who understood who the professionals were to refer patients to for diagnosis of ASDs. Less improvement (10%) was seen in their knowledge about the availability of schools and resources for children with ASDs. However, the participants asked the facilitators after the workshops for an information leaflet on this, so that they could make proper referrals. A 50% increase in knowledge was seen with regards to the conditions comorbid with ASDs (e.g. mental illnesses such as attention deficit hyperactivity disorder and anxiety disorder). With regards to the causes of ASDs, all participants (n=10) provided either a partially correct (30%) or correct (70%) answer after the workshops, in contrast to the 50% of participants who were completely wrong before training. The majority of participants (90%) knew which facility to refer children with ASDs to after the training, which shows an increase of 10%. It could therefore be expected that the registered nurses who took part in this training would refer children for diagnosis to the tertiary hospital.[4] A more significant improvement was seen in their knowledge of treatment approaches for ASDs. Prior to training, only 30% of the registered nurses had some idea of the different treatment approaches, compared to 60% following the training. These registered nurses had received

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Behavioural problems Dislike touch Do not always respond to auditory stimuli Show a lack of fear for danger Avoid eye contact Are preoccupied with own thoughts Are less flexible in adapting to changing routines Focus on one activity at a time Explore the environment inappropriately, e.g. licking, smelling, handling of objects Injure themselves by banging head against table, etc.

general training that did not include specialised training in psychiatrics or paediatrics, and they had no prior knowledge of ASDs. It is therefore suggested that registered nurses collaborate with other members of health teams in order to meet the healthcare needs of the public.[11]

Discussion

Based on the overall results, it can be seen that participantsâ&#x20AC;&#x2122; knowledge improved and that they developed a better understanding of the condition. The information leaflet that we provided upon request, with contact numbers of appropriate schools, was considered helpful in advising parents on educational options. These workshops raised awareness of ASDs among the participants, but there remains a need for added support. Registered nurses in PHC clinics are not expected to diagnose ASDs, but they should be made aware of the risk factors and associated characteristics. They should additionally be able to refer parents to specialists and schools for learners with special educational needs. Support should ideally be provided on a continual basis, to refresh their knowledge and to accommodate colleagues who could not attend the original presentations. It was found to be valuable to have discussion groups following training, because the nurses showed a need to discuss the relevant issues pertaining to the topic. The limitations of the study were the low attendance and small sample size. The low attendance (high attrition rate) of the nurses at the two clinics can be attributed to the nature of their work, as shift schedules complicated this matter. As the specific dates for training were predetermined by the Gauteng Department

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Learning characteristics Hypersensitivity or hyposensitivity to sensory stimuli such as textures, taste, smells, sounds, visual input, pain Poor fine motor skills, e.g. difficulty holding a pencil, drawing or writing, etc. Gross motor difficulties, e.g. coordination and balance problems, etc. Easily frustrated

of Health for staff development purposes, no flexibility was possible, and so we could not accommodate all the registered nurses. In addition, this project allowed only two clinics to be included in the research. Future support programmes should be conducted in all clinics in the catchment area of the hospital, before an increased referral rate to specialists for early diagnosis of ASDs is likely to be seen. The results of this study should be interpreted with regards to the limited sample size. Purposive sampling further limits the generalisation of these results to other contexts.

Conclusion

The programme was presented in an effective manner, and participants gained knowledge about ASDs. This condition remains a challenge, owing to the global increase in its prevalence.[20] ASDs should be addressed in nursesâ&#x20AC;&#x2122; professional training, so that they can identify behaviour, symptoms and risk factors, in order to refer these children for diagnosis at an early age, which will improve the prognosis of the condition. A multidisciplinary approach where speechlanguage therapists (SLTs) and registered nurses work together in the early identification and referral of children with possible ASDs is needed. In accordance with their scope of practice, SLTs should provide support to registered nurses in PHC to enhance their knowledge of ASDs. Effective support by SLTs should be based on interprofessional teamwork, and on encouraging adequate attendance of workshops. However, shift schedules are not necessarily flexible, and it may be necessary to repeat workshops to accommodate more registered nurses. The scheduling of

Research workshops for continuing professional development is an administrative matter that needs to be negotiated with the Department of Health. Acknowledgements. We wish to acknowlege the following students for the data collection: Caley-Jade Selepe, Duduzile Nhlapo, Glen Shivambu and Kgaugelo Tema. Author contributions. Equal contributions. Funding. None. Conflicts of interest. None. 1. Newschaffer CJ, Croen LA, Daniels J, et al. The epidemiology of autism spectrum disorders. Annu Rev Public Health 2007;28(1):235-258. https://doi.org/10.1146/annurev.publhealth.28.021406.144007 2. Thema LK, Singh S. Integrated primary oral health services in South Africa: The role of the PHC nurse in providing oral health examination and education. Afr J Prim Health Care Fam Med 2013;5(1):1-4. https://doi. org/10.4102/phcfm.v5i1.413 3. Karande S. Autism: A review for family physicians. Indian J Med Sci 2006;60(5):205-215. https://doi. org/10.4103/0019-5359.25683 4. Bonis S. Stress and parents of children with autism: A review of the literature. Issues Ment Health Nurs 2016;37(3):153-163. https://doi.org/10.3109/01612840.2015.1116030 5. Boyd BA, Odom SL, Humphreys BP, Sam AM. Infants and toddlers with autism spectrum disorder: Early identification and early intervention. J Early Interv 20101;32(2):75-98. https://doi. org/10.1177%2F1053815110362690 6. Bakare MO, Ebigbo PO, Agomoh AO, et al. Knowledge about childhood autism and opinion among healthcare workers on availability of facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders in Nigeria. BMC Pediatr 2009;9(1):12. https://doi.org/10.1186/1471-2431-9-12

7. Mandell DS, Wiggins LD, Carpenter LA, et al. Racial/ethnic disparities in the identification of children with autism spectrum disorders. Am J Public Health 2009;99(3):493-498. https://doi.org/10.2105/AJPH.2007.131243 8. Bakare MO, Munir KM. Autism spectrum disorders (ASD) in Africa: A perspective. Afr J Psychiatry 2011;14(3):208-210. https://doi.org/10.4314/ajpsy.v14i3.3 9. Bowker A, D’Angelo NM, Hicks R, Wells K. Treatments for autism: Parental choices and perceptions of change. J Autism Dev Disord 2011;41(10):1373-1382. https://doi.org/10.1007/s10803-010-1164-y 10. Beukelman D, Mirenda P. Augmentative and alternative communication: Supporting children and adults with complex communication needs. Baltimore: Paul Brooks, 2012. 11. Van der Linde J, Kritzinger A. Perceptions of rural primary healthcare personnel about expansion of early communication intervention: Original research. Afr J Prim Health Care Fam Med 2013;5(1):1-11. https://doi. org/10.4102%2Fphcfm.v5i1.553 12. Weissman L, Bridgemohan C. Autism spectrum disorder in children and adolescents: Overview of management. UpToDate, 2018. https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescentsoverview-of-management (accessed 13 May 2018). 13. Christensen DL, Bilder DA, Zahorodny W, et al. Prevalence and characteristics of autism spectrum disorder among 4-year-old children in the autism and developmental disabilities monitoring network. J Dev Behav Pediatr 2016;37(1):1-8. https://doi.org/10.1097/DBP.0000000000000235 14. Elder JH, D’Alessandro T. Supporting families of children with autism spectrum disorders: Questions parents ask and what nurses need to know. Pediatr Nurs 2009;35(4):240. 15. Henderson K. Policies and practices used by states to serve children with autism spectrum disorders. J Disabil Policy Stud 2011;22(2):106-115. https://doi.org/10.1177/1044207310396210 16. Hall HR, Graff JC. The relationships among adaptive behaviors of children with autism, family support, parenting stress, and coping. Issues Compr Pediatr Nurs 2011;34(1):4-25. https://doi.org/10.3109/01460862.2011.555270 17. Thomas EJ, Rothman J. Intervention Research: Design and Development for Human Service. Haworth: Boston, 1994. 18. Matson JL, Kozlowski AM. The increasing prevalence of autism spectrum disorders. Res Autism Spectr Disord 2011;5(1):418-425. https://doi.org/10.1016/j.rasd.2010.06.004

Accepted 10 October 2017.

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CPD questionnaire June 2018 True (A) or false (B) AIMED AT ITCHEDD: A proof-of-concept study to evaluate a mnemonic-based approach to clinical reasoning in the emergency medical care educational setting 1. The respondents in this study found the mnemonic useful in guiding students through the critical thinking and decision-making processes.

Establishing consensus among inter-professional faculty on a gender-based violence curriculum in medical schools in Nigeria: A Delphi study 12. Preparedness of students was one of the main reasons cited by stakeholders as to why gender-based violence should be taught at medical school.

Association between personality factors and consulting specialty of practice of doctors at an academic hospital in Bloemfontein, South Africa 2. A previous study using the Cloninger Inventory found that those students choosing internal medicine had lower harm-avoidance scores than those choosing surgery and emergency medicine. 3. The five personality factors that were explored in this study include impulsive sensation seeking, neuroticism-anxiety, aggression-hostility, sociability and activity.

Self-reported generic learning skills proficiency: Another measure of medical school preparedness 13. Research has shown that students experiencing academic difficulties in their first year at medical school report problems with information handling, problem-solving, critical thinking and time management. 14. This study showed that the self-reported confidence in generic learning skills proficiency of first-year medical students was related to three objective measures of performance: pre-university admission aptitude test scores, information technology proficiency on entry to university and early academic performance at university.

Optometry students’ attitudes towards research at undergraduate level 4. The negative statements of respondents related mostly to group work. 5. The tripartite attitude model comprises an affective/emotive, behavioural and cognitive component. Factors causing stress among first-year students attending a nursing college in KwaZulu-Natal, South Africa 6. Research has shown that self-concept positively affects the success of nursing students’ ability to manage anxiety and stress related to studying. 7. It is well known that stress factors that affect students attending a large university are different from those of students who attend smaller tertiary institutions. ‘Pain and stress are part of my profession’: Using dental practitioners’ views of occupation-related factors to inform dental training 8. Dental training in the South African context, occupational health experiences, self-care and burnout, coping strategies and dental education were the main themes identified in this research. 9. One of the stressors that was strongly recognised in this study was the challenges of teamwork. Occupational therapy students’ use of social media for professional practice 10. There is a growing trend of incorporating social media for professional purposes into health professions education. 11. In our study, there was an incline in the frequency of YouTube use as students progressed to their final year.

Integrating critical cross-field outcomes in an anatomy course at a university of technology: A reflective perspective 15. Contemporary studies suggest that to improve and promote student learning, current curricula must explore and maximise the benefits of different teaching methods. 16. Studies have shown that peer learning has a minimal effect on the development of collaboration and communication skills. Strengths and challenges of community-based clinical training as viewed by academics at the University of KwaZulu-Natal, Durban, South Africa 17. Community-based clinical training is seen as a valuable tool for transforming health professions education to meet graduate competencies and the needs of the health system. 18. Improved service delivery was found to be the primary benefit of community-based education to communities in this study. A support programme for registered nurses in the early identification of autism spectrum disorders in primary healthcare clinics: A pilot study 19. A comprehensive diagnostic evaluation of autism spectrum disorders involves a multidisciplinary team comprised of a paediatric nurse, psychiatrist, psychologist, neurologist, speech-language therapist and occupational therapist. 20. A comparison of pre- and post-training scores showed a minimal increase in the level of understanding of specific problems associated with autism.

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The CPD programme for AJHPE is administered by Medical Practice Consulting. CPD questionnaires must be completed online at www.mpconsulting.co.za After submission you can check the answers and print your certificate. Questions may be answered up to 6 months after publication of each issue. Accreditation number: MDB015/029/01/2018 (Clinical)

June 2018, Vol. 10, No. 2 AJHPE